







LIBRARY OF CONGRESS. 




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UNITED STATES OF AMERICA. 









A TREATISE 



ON 



THE SCIENCE AND PRACTICE 



OF 



MIDWIFEEY. 



BY 

W. S. PLAYFAIR, M.D., LL.D., F.R.C.P., 

'PHYSICIAN-ACCOUCHEUR TO H.I. AND R. H. THE DUCHESS OF EDINBURGH; PROFESSOR OF OBSTETRIC 

MEDICINE IN KING'S COLLEGE ; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO 

KING'S COLLEGE HOSPITAL ; CONSULTING PHYSICIAN TO THE GENERAL LYING-IN 

HOSPITAL, AND TO THE EVELINA HOSPITAL FOR CHILDREN ; LATE PRESIDENT 

OF THE OBSTETRICAL SOCIETY OF LONDON J EXAMINER IN MIDWIFERY 

TO THE UNIVERSITIES OF CAMBRIDGE AND LONDON AND TO 

THE ROYAL COLLEGE OF PHYSICIAN?. 



SIXTH AMERICAN FROM THE EIGHTH ENGLISH EDITION. 

WITH NOTES AND ADDITIONS 

By ROBERT P. HARRIS, A.M., M.D., 

HONORARY FELLOW OF THE AMERICAN GYNAECOLOGICAL SOCIETY, AND OF THE PHILADELPHIA 

OBSTETRICAL SOCIETY; CORRESPONDING MEMBER OF THE OBSTETRICAL SOCIETY OF LEIPZIG, 

AND OF THE ROYAL MEDICO-CHIRURGICAL ACADEMY, OF NAPLES, ETC. 

WITH FIVE PLATES AND TWO HUNDRED AND SEVENTEEN ILLUSTRATIONS. 








PHILADELPHIA: 

LEA BROTHERS & CO. 

1893. 



5*^ 



12- 



Entered according to the Act of Congress, in the year 1893, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



DOENAN, PRINTER. 
PHILADELPHIA. 



EDITOR'S PREFACE TO SIXTH AMERICAN EDITION. 



DuKING the intervening four years since the last American 
edition was issued, very decided advances have been made in the 
field of obstetric surgery, particularly in the adoption of methods 
that have resulted in the saving of human life. The conservative 
Csesarean operation in the most carefully managed European mater- 
nities, and even in the general practice in our own country, may be 
honestly claimed to save 90 per cent, of the Avomen — 16 having died 
out of 160 cases in certain European hospitals, and 2 out of the 
last 20 in the United States. The Porro-Ceesarean record of all 
countries now shows a mortality which has been reduced to 14 per 
cent., as proven by the record of 1890-1891 ; and the sub-peritoneal, 
replacing the fatal intra-peritoneal method, has saved 22 women out 
of 25. The introduction of symphyseotomy into our country a year 
ago, has required us to give a special notice to this operation, now 
so largely performed in Europe, and attracting a growing attention 
here, because of its possibilities of success. The term laparotomy, 
and the prefix laparo-, as applied to abdominal surgery, and not to 
flank-incisions, have been abandoned throughout the volume, and 
the term coeliotomy, and the prefix C02U0-, substituted for them. 
Craniotomy having fallen in the estimation of American obstetri- 
cians, and some of the younger thinkers of Great Britain, because of 
the diminishing dangers of Csesarean and symphyseotomic deliveries, 
the American editor has striven to do away with the leaning of the 
English author toward a preference for the infantile destructive 
method, begotten of opinions based upon comparative results which 
were prevalent, and thought to be well founded, forty years ago. 
Notes and additions of the American editor are enclosed in 
brackets [ ]. 



329 South Twelfth Street. Philadelphia. 
September, 1893. 



(iii) 



AUTHOR'S PREFACE TO THE EIGHTH EDITION. 



The large edition of this Treatise which was published in the 
spring of L889 being completely exhausted, the author has subjected 
the work to a thorough revision. Since 1889 much progress has 
been made in certain departments of obstetrics which has necessitated 
changes, amounting to the almost complete rewriting of some of the 
chapters, as, for instance, those on extra-uterine pregnancy, the 
Cesarean section, symphyseotomy, and puerperal septicaemia. Sev- 
eral new illustrations have also been added. He trusts that these 
alterations may make the present edition a satisfactory guide to the 
most recent advances in obstetric medicine, and secure for it the 
same favorable reception which the profession has given to its 
predecessors, for which he feels very grateful. He has to express his 
thanks for many letters he has received from students of medicine, 
in all parts of the country, containing criticisms and suggestions, 
which all show how carefully the book had been studied, and some of 
which he has adopted, amongst them the addition of a separate index 
to the first volume. He has also to express his obligations to his 
friend and colleague Dr. John Phillips, who, it is to be feared at 
much inconvenience to himself, has again carefully revised the proof- 
sheets, and also to his cousin, Dr. Hugh Playfair, for assistance 
in the same tedious task. 

31 George Street, Hanover Square, W. 
March, 1893. 



(V) 



AUTHOR'S PREFACE TO THE FIRST EDITION. 



Those who have studied the progress of Midwifery know that 
there is do department of medicine in which more has been done of 
late years, and none in which modern views of practice differ more 
widely from those prevalent only a short time ago. The Author's 

object has been to place in the hand- of his readers an epitome of 
the science and practice of midwifery which embodies all recent 
advances. He is aware that on certain important points he has 
amended practice which nor long ago would have been consid- 
ered heterodox in the extreme, and which, even now, will not meet 
with general approval. He has, however, the satisfaction of know- 
ing that he has only done so after very deliberate reflection, and 
with the profound conviction that such changes are right, and that 
they will stand the test of experience. He has endeavored to dwell 
especially on the practical part of the subject, so as to make the work 
a useful guide in this most anxious and most responsible branch of 
the profession. It is admitted by all. that emergencies and difficul- 
ties arise more often in this than in any other branch of practice : 
and there is no part of the practitioner's work which requires more 
thorough knowledge or greater experience. It is. moreover, a lamen- 
table tact that student- generally leave their schools more ignorant of 
obstetrics than of any other subject. So long. as the absurd regula- 
tion- exist which oblige the lecturer on midwifery to attempt the 
impossible task of teaching obstetrics in a short three months' course 
— an absurdity which has over and over again been pointed out — 
such must of necessity be the case. This must be the Author's 
excuse for dwelling on many topics at greater length than some will 
doubtless think their importance merits, since he desire- to place in 
the hands of his student- a work which may in some measure supply 
the inevitable defects of his lectures. 

(vii) 



vm 

Many of the illustrations are copied from previous authors, while 
some are original. The following quotation from the preface to 
Tyler Smith's Manual of Obstetrics will explain why the source 
of the copied woodcuts has not been in each instance acknowledged: 
""When I began to publish, I determined to give the authority for 
every woodcut copied from other works. I soon found, however, 
that obstetric authors of all countries, from the time of Mauriceau 
downward, had copied each other so freely without acknowledgment 
as to render it difficult or impossible to trace the originals." 

The Author has to express his acknowledgments to many friends 
for their kind assistance by the loan of illustrations and otherwise, 
and more especially to his colleague, Dr. Hayes, for his valuable 
aid in passing the work through the press. 

31 George Street, Hanover Square. 
March, 1876. 



CONTENTS. 



PART I. 

ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 
IN PARTURITION 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

PAGE 

Its importance — Formation of pelvis— The os innominatum ; its three divisions 
— Separation between the true and false pelvis — The sacrum and coccyx — 
Mechanical relations of the sacrum — Pelvic articulations and ligaments — 
Movements of the pelvic joints— The pelvis as a whole — Differences in the 
two sexes — Measurements of the pelvis— Its diameters, planes, and axes — 
Development of the pelvis — Soft parts in connection with the pelvis . . 33 

CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to function : 1. External or copulative ; 2. Internal or for- 
mative organs — Mons Veneris — Labia majora and minora — The clitoris — 
The vestibule and orifice of the urethra — Passing of the female catheter — 
Orifice of vagina — The hymen — Caruncula? myrtiformes — The glands of 
the vulva — The perineum— The vagina— The uterus: its position and 
anatomy — [Partitioned uterus] — The ligaments of the uterus — The paro- 
varium— The Fallopian tubes — The ovaries — The Graafian follicles and 
the ova — The mammary glands . 49 

CHAPTER III. 

OVULATION AND MENSTRUATION. 

Functions of the ovary — Changes in the Graafian follicle: 1. Maturation; 2. 
Escape of the ovum — Formation of the corpus luteum — [Precocious 
physical womanhood] — Quality and source of the menstrual blood — Theory 
of menstruation — Purpose of the menstrual loss — Vicarious menstruation 

— Cessation of menstruation 82 

(ix) 



CONTENTS. 

PART II. 

PREGNANCY. 



CHAPTER I. 

CONCEPTION AND GENERATION. 

PAGE 

The semen— Site and mode of impregnation — Changes in the ovum — Cleavage 
of the yelk — The decidua and its formation — Formation of the amnion — 
The umbilical vesicle and allantois — The liquor amnii and its uses — The 
chorion — The placenta ; its formation, anatomy, and functions 96 

CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

Appearance of the fetus at various stages of development — [Very small foetuses 
habitually produced by some mothers] — Anatomy of the fcetal head — The 
sutures and fontanelles — Influence of sex and race on the foetal head — 
Position of the foetus in utero — Functions of the foetus— The foetal circu- 
lation 122 

CHAPTER III. 

PREGNANCY. 

Changes in the form and dimensions of the uterus — Changes in the cervix — 
Changes in the texture of the uterine tissues, the peritoneal, muscular, and 
mucous coats — General modifications in the body produced by pregnancy . 137 

CHAPTER IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

Signs of a fruitful conception — Cessation of menstruation —Sympathetic disturb- 
ances — Morning sickness, etc. — Mammary changes — Enlargement of the 
abdomen — Quickening — Intermittent uterine contractions— Vaginal signs 
of pregnancy — Ballottement, etc. — Auscultatory signs of pregnancy — Foetal 
pulsations — Uterine souffle, etc 149 

CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY — SPURIOUS PREGNANCY — 
THE DURATION OF PREGNANCY — SIGNS OF RECENT PREGNANCY. 

Adipose enlargement of the abdomen — Distention of the uterus by retained 
menses, etc — Congestive enlargement of uterus — Ascites — Uterine and 
ovarian tumors— Spurious pregnancy ; its causes, symptoms, and diagnosis 
— The duration of pregnancy — Sources of fallacy — Methods of predicting 
the date of delivery — Protraction of pregnancy — Signs of recent delivery . 164 



CONTENTS. XI 



CHAPTER Vr. 



ABNORMAL PREGNANCY, INCI.l'DlNC MULTIPLE PREGNANCY, SUPER- 
FCETATIONj EXTRA-UTERINE FCETATION, AND BUSSED LABOR. 

PAGE 

Plural births; their frequency, relative frequency in different countries, causes, 
etc- — Super-fcetation and super-fecundation — Nature — Explanation— Objec- 
tions to admission of such cases — Their possibility admitted — Extra-uterine 
pregnancy — Classification— Causes — Tubal pregnancies — Changes in the 
Fallopian tubes — Condition of uterus — Progress and termination — Diag- 
nosis—Treatment — Abdominal pregnancy; description, diagnosis, treat- 
ment — Missed labor; its symptoms, causes, and treatment - [Causes of 
missed labor] 173 



CHAPTER VII. 

DISEASES OF PREGNANCY. 

Some only sympathetic, others mechanical or complex in their origin — De- 
rangement of the digestive organs; excessive nausea and vomiting, 
diarrhoea, constipation, hemorrhoids, ptyalism, dyspnoea, etc. — Palpitation 
— Syncope — Anaemia and chlorosis— Albuminuria ..... 203 

CHAPTER VIII. 

diseases of pregnancy {continued). 

Disorders of the nervous system ; insomnia, headaches and neuralgia, paralysis 
— Chorea; disorders of the urinary organs; retention of urine, irritability 
of the bladder, incontinence of urine, phosphatic deposits — Leucorrhoea — 
Effects of pressure — Laceration of veins — Displacements of the gravid 
uterus ; prolapse, anteversion, retroversion — Diseases coexisting with 
pregnancy ; eruptive fevers, smallpox, measles, scarlet fever, continued 
fever, phthisis, cardiac disease, syphilis, icterus, carcinoma — Pregnancy 
complicated with ovarian and fibroid tumors ...... 217 

CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the decidua — Hydro rrhoea gravidarum — Pathology of the 
chorion; vesicular degeneration, myxoma fibrosum— Pathology of the 
placenta; blood extravasations, fatty degeneration, etc. — Pathology of the 
amnion — [Hydramnios] — Deficiency of liquor amnii, etc — Pathology of 
of the umbilical cord —Pathology of the foetus ; blood diseases transmitted 
through the mother : smallpox, measles, and scarlet fever, intermittent 
fevers, lead-poisoning, syphilis —Inflammatory diseases — Dropsies — Tumors 
— "Wounds and injuries of the foetus — Intra-uterine amputations — [Arrested 
pullulation] —Death of the foetus 234 



Xll CONTENTS. 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

PAGE 

Importance and frequency — Definition and classification —Frequency — Recur- 
rence — Causes — Causes referable to foetus — Changes in a dead ovum re- 
tained in uiero — Extravasations of blood — Moles, etc. — Causes depending 
on maternal state, syphilis — Causes acting through nervous sytem, physical 
causes, etc. — Causes depending on morbid states of uterus— Symptoms — 
Preventive treatment — Prophylactic treatment — Treatment when abortion 
is inevitable — After-treatment 252 



PAKT III. 

LABOR. 



CHAPTER I. 



THE PHENOMENA OF LABOR. 



Causes of labor — Mode in which the expulsion of the child is effected — The 
uterine contraction — Mode in which the dilatation of the cervix is effected — 
Rupture of the membranes — Character and source of pains during labor— 
Effects of pains on mother and fetus — Division of labor into stages — Pre- 
paratory stage — False pains — First stage —Second stage — Third stage — 
Mode in which the placenta is expelled— Duration of labor . . . 265 

CHAPTER II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of subject — Frequency of head presentations — The different posi- 
tions of the head — First position — Division of mechanical movements into 
stages —Flexion — Descent and levelling movement— Rotation — Extension 
— External rotation — Second position — Third position —Fourth position — 
Caput succedaneum — Alteration in shape of head from moulding . . 278 

CHAPTER III. 

MANAGEMENT OF NATURAL LABOR. 

Preparatory treatment — Dress of patient during pregnancy — The obstetric bag 
■ — Duties on first visiting patient — Antiseptic precautions — False pains — 
[Kelly's rubber protector in parturient cases] — Their character and treat- 
ment — Vaginal examination — The position of patient — Artificial rupture 
of membranes — Treatment of propulsive stage — Relaxation of the peri- 
neum — Treatment of lacerations — Expulsion of child — Promotion of 
uterine contraction— Ligature of the cord — Management of the third stage 
of labor — [Expulsion of placenta] — Application of the binder — After- 
treatment ."...». 290 



CONTENTS. XI 11 



CHAPTER IV. 



AN ESTHESIA IN LABOR. 

PAGK 

Agents employed — Chloral : its object and mode of administration — Ether — 
Chloroform; its use, objections to, and mode of administration — [Ether 
safer than chloroform] . 308 



CHAPTER V. 



PELVIC PRESENTATIONS. 



Frequency — Causes — Prognosis to mother and child — Diagnosis by abdominal 
palpation and by vaginal examination — [Bimanual version in breech cases] 
— Differential diagnosis of breech, knee, and foot — Mechanism — Treatment 
— Management of impacted breech presentations — [Breech forceps] . . 312 



CHAPTER VI. 

PRESENTATIONS OF THE FACE. 



Erroneous views formerly held on the subject — Frequency — Mode of production 
— Diagnosis — Mechanism — Four positions of the face — Description of de- 
livery in first face position — Mento-posterior position in which rotation 
does not take place — Prognosis — Treatment — Brow presentation . . 323 



CHAPTER VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

Causes of face-to-pubes delivery — Mode of treatment — Upward pressure on 
forehead — Downward traction on occiput — Use of forceps — Peculiarities 
of forceps delivery — [Version by the vertex] — [Use of the hand in occipito- 
posterior positions] . . . . . m 333 

CHAPTER VIII. 

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK— COMPLEX PRESENTATIONS 
— PROLAPSE OF THE FUNIS. 

Position of the foetus — Division into dorso-anterior and dorso posterior posi- 
tions — Causes— Prognosis and frequency — Diagnosis — Mode of distinguish- 
ing position of child — Differential diagnosis of shoulder, elbow, and hand 
— Mechanism — The two possible modes of delivery by the natural powers 
— Spontaneous version — Spontaneous evolution — Treatment — [Cesarean 
operation for foetal impaction] — Complex presentation : foot or hand with 
head; hand and feet together — Dorsal displacement of the arm — Prolapse 
of the umbilical cord — Frequency — Prognosis — Causes— Diagnosis — Postu- 
ral treatment — Artificial reposition — Treatment when reposition fails . 336 



XIV CONTENTS. 

CHAPTER IX. 

\ 

PROLONGED AND PRECIPITATE LABORS. 

PAGE 

Evil effects of prolonged labor — Influence of the stage of labor in protraction — 
Delay in the first stage rarely serious — Temporary cessation of pains — 
Symptoms of protraction in the second stage — State of the uterus in pro- 
tracted labor — Cases of protraction due to morbid condition of the expul- 
sive powers — Causes of protraction — Treatment — Oxytocic remedies — 
Ergot of rye, etc. — Manual pressure — Instrumental delivery (case of 
Princess Charlotte of Wales) — Precipitate labor— Its causes and treatment 
— [Eapid delivery] 351 

CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the cervix : its causes, effects, and treatment — [Csesarean section in 
cancer of the cervix] — Ante-partum hour-glass contraction — Bands and 
cicatrices in the vagina — Extreme rigidity of the perineum — Labor com- 
plicated with tumor — [Csesarean results in tumor cases] —Vaginal cystocele 
—Calculus— Hernial protrusions — [Impaction of bowels from eating clay] — 
(Edema of vulva — Haematic effusions, etc.— [Polypus obstructing delivery] 366 

CHAPTER XI. 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE 

FCETUS. 

Plural births, treatment of — Locked twins — Conjoined twins — Intra-uterine 
hydrocephalus: its dangers, diagnosis, and treatment — Other dropsical 
effusions— Foetal tumors — Excessive development of foetus . . .379 

CHAPTER XII. 

DEFORMITIES OF THE PELVIS. 

Classification — Causes of pelvic deformity — [Rickets and osteomalacia] — The 
equally enlarged pelvis — The equally contracted pelvis — The undeveloped 
pelvis — [External characteristics of a large and tall woman] — Masculine or 
funnel-shaped pelvis — Contraction of conjugate diameter of brim — Scolio- 
rhachitic pelvis — Figure-of-eight deformity — Spondylolisthesis — [True 
character of spondylolisthetic deformity] — Spondylolizema — Narrowing 
of the oblique diameters — Obliquely contracted pelvis — [Coxalgic deformity 
of pelvis] — Kyphotic pelvis — Robert's pelvis— Deformity from old-stand- 
ing hip-joint disease — Deformity from tumors, fractures, etc — Effects of 
contracted pelvis on labor — Risks to the mother and child — [Pelvic exos- 
toses obstructing delivery] — Mechanism of delivery in head presentation ; 
o, in contracted brim; b, in generally contracted pelvis— Diagnosis— Ex- 
ternal measurements — Internal measurements — Mode of estimating the 
conjugate diameter of the brim— Mode of diagnosticating the oblique pelvis 
— Treatment — The forceps — Turning - Craniotomy— [Symphyseotomy] — 
The induction of premature labor — Induction of abortion — [Dangers of 
Cesarean section overestimated] . 391 



CO NT KB xv 

Mil. 
BEFORE DELIVERY — PLACENTA PR 

PAGE 

Detin:- -—Symptoms — Sour - fhemorrfa _ 

— Treatment — [Braxton Hicks's bimanual method of turning in placenta 
pnevia] . 41 > 

CHAPTER XIV. 

HEMORRHAGE PROM SEPARATION OF A NORMALLY SITUATED PLACENTA. 

iogy — Symptoms and diagnosis— Progn.-is — Treatment . 430 

CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

Its frequency — Generally a preventable accident — Causes — Nature's method of 
controlling hemorrhage — Uterine contraction— Thrombosis — Secondary 
causes of hemorrhage — Irregular uterine contraction — Placental adhesions 
— Constitutional predisposition to flooding — Symptoms — Preventive treat- 
ment — Curative treatment — Secondary treatment — [Head lowered and 
bxly elevated in tainting from hemorrhage] — Secondary post-partum 
hemorrhage — Its causes and treatment ....... 433 



CHAPTER XVI. 

RUPTURE OF THE UTERUS I 

ty — Se " of rupture — Causes, piedis] sing and exciting — Symptoms — 
Prognosis — Treatment : when the foetus remains in utero ; when the foetus 
has escaped from the uterus — [Supra-vaginal hysterectomy no right or title 
to name of Porro] — Lacerations of the cervix — Recapitulation — Lacerati a - 
of the vagina — Vesico- and recto-vaginal fl<tuke — Their mode of formation 
— Treatment — [Rational treatment of rupture of uterus] . . . .451 



CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Division into acute and chronic forms — Description — Symptoms — Diagn-i — 
Mode of production — Treatment — [Spontaneous reposition of the inverted 
uterus 46: 



XVI CONTENTS. 

PART IY. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PREMATURE LABOR. 

PAGE 

History — Objects — May be performed on account of either the mother or child 
— Modes of inducing labor — Puncture of membranes — Administration of 
oxytocics — Means acting indirectly on the uterus — Dilatation of cervix — 
Separation of membranes — Vaginal and uterine douches — Introduction of 
flexible catheter — [Infantile mortality after induction of premature labor] — 
Rearing of the child 469 



CHAPTER II. 

TURNING. 

History — Turning by external manipulation — Object and nature of the opera- 
tion — Cases suitable for the operation — Statistics and dangers — Method of 
performance — Cephalic version —Method of performance — Podalic version 
— Position of patient— Administration of anaesthetics — Period when the 
operation should be undertaken —Choice of hand to be used — Turning by 
bi-polar method — Turning when the hand is introduced into the uterus — 
Turning in abdomino-anterior positions —Difficult cases of arm presentation 479 

CHAPTER III. 

THE FORCEPS. 

Frequent use of the forceps in modern practice — Description of the instrument 
— The short forceps — Its varieties — The long forceps — Suitable to all cases 
alike — Action of the instrument — Its power as a tractor, lever, and com- 
pressor — Preliminary considerations before operation — Use of anaesthetics 
— Description of the operation — Low forceps operation — High forceps 
operation — Possible dangers of forceps delivery — Possible risks to the 
child— [The forceps in America] . 494 

CHAPTER IV. 

THE VECTIS — THE FILLET. 

Nature of the vectis — Its use as a lever or tractor — Cases in which it is appli- 
cable -Its use as a rectifier of malpositions — The fillet — Nature of the 
instrument — Objection to its use ........ 519 



CONTENTS. XVll 

CHAPTER V. 

OPERATION* INVOLVING DESTRUCTION OK THE FOETUS. 

PAGE 

Their antiquity and history — Division of subject — Nature of instruments 
employed — Perforator — Crochet — Craniotomy forceps — Cephalotribe — 
Forceps-saw — Ecraseur — Basilyst — Cases requiring craniotomy — Method 
of Perforation— Extraction of the head — Comparative merits of cephalo- 
tripsy and craniotomy — Extraction by the craniotomy forceps — Extrac- 
tion of the body — [Meigs's craniotomy forceps] — Embryotomy — Decapita- 
tion and evisceration 521 

CHAPTER VI. 

THE CESAREAN SECTION — PORRO'S OPERATION. 

History of the operation — [Horn-rip — Macduff's delivery] — Statistics — [Old 
Csesarean records of little practical value now — Csesarean section in 
America] — Results to mother and child— Cases requiring operation — 
[Csesarean section under relative indications] — Post-mortem Csesarean sec- 
tion — Causes of death after Csesarean section — Preliminary preparations — 
Description of the operation — Subsequent management — Porro's operation 
— [Csesarean section of 1893] — Substitutes for the Csesarean section . . 537 



CHAPTER VII. 

CCELIO-ELYTROTOMY — SYMPHYSEOTOMY. 

History — Nature of the operation — Advantages over the Csesarean section — 
Cases suitable for the operation — Anatomy of the parts concerned in the 
operation — Method of performance — Subsequent treatment— Symphyse- 
otomy — History — Its recent reintroduction into practice — Method of per- 
formance — [Harris's symphyseotomy bistoury — Progress and results of 
symphyseotomy — Statistics — Operation after induced labor — Unilateral 
ischio-pubiotomy] 553 



CHAPTER VIII. 

THE TRANSFUSION OF BLOOD. 

History — Nature and object of the operation — Use of blood taken from the 
lower animals — Difficulties from coagulation of fibrin — Modes of obviat- 
ing them — Immediate transfusion — Addition of chemical agents to prevent 
coagulation — Defibrination of the blood — Statistical results— Possible dan- 
gers of the operation — Cases suitable for transfusion — Description of the 
operation — Schafer's directions for immediate transfusion — Effects of suc- 
cessful transfusion — Secondary effects of transfusion — [Transfusion with 
defibrinated blood] 564 



XVlll CONTENTS. 

PART V. 

THE PUEBPERAL STATE. 



CHAPTER I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

PAGE 

Importance of studying the puerperal state — The mortality of childbirth — 
Alterations in the blood after delivery — Condition after delivery — Nervous 
shock — Fall of the pulse — The secretions and excretions — Secretion of 
milk — Changes in the uterus after delivery — The lochia — The after-pains 
— Management of women after delivery — Treatment of severe after-pains — 
Diet and regimen 575 

CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC 

Commencement of respiration after the birth of the child — Apparent death of 
the newborn child — Its treatment — Washing and dressing the child — 
Application of the child to the breast — The colostrum and its properties — 
Secretion of milk — Importance of nursing — Selection of a wet-nurse- 
Management of lactation — Diet and regimen of nursing women — [Diet 
proper for wet-nurses] — Period of weaning— Disorders of lactation — Means 
of arresting the secretion of milk — Defective secretion of milk — [Milk diet 
for nursing mothers] — Depressed nipples — Fissures and excoriations of the 
nipples — Excessive flow of milk — Mammary abscess— Hand-feeding — 
Causes of mortality in hand-feeding — Various kinds of milk — Method of 
hand-feeding 586 

CHAPTER III. 

PUERPERAL ECLAMPSIA. 

Its doubtful etiology — Premonitory symptoms — Symptoms of the attack — Con- 
dition between the attacks — Relation of the attacks to labor — Results to 
mother and child — Pathology — Treatment — Obstetric management — [Urine 
to be examined in eclamptic cases] 603 

CHAPTER IV. 

PUERPERAL INSANITY. 

Classification — Proportion of various forms — Insanity of pregnancy — Predispos- 
ing causes — Period of pregnancy at which it occurs — Type of insanity — 
Prognosis — Transient mania during delivery — Puerperal insanity (proper) 
—Type of insanity — Causes — Theory of its dependence on a morbid state 
of the blood — Objections to the theory — Prognosis — Post-mortem signs — 
Duration — Insanity of lactation — Type —Symptoms — Of mania — Of melan- 
cholia — Treatment — Question of removal to asylum — Treatment during 
convalescence 612 



CONTENTS. xix 

CHAPTEB v. 

PUERPERAL SEPTICEMIA. 

PAGE 

Differences of opinion — Confusion from this cause — Modern view of this disease 
— History — Its mortality in lying-in hospitals— Numerous theories :is to 
its nature — Theory of local origin — Theory of an essential zymotic fever — 
Theory of its identity with surgical septicaemia — Nature of this view — 
Channels through which septic matter may be absorbed — Character and 
origin of septic matter often obscure — Division into autogenetic and hetero- 
genetic cases — Objections to term "autogenetic" — Sources of saprsemia — 
Sources of heterogenetic infection— Influence of cadaveric poison — Infec- 
tion from erysipelas — Infection from other zymotic diseases — Infection 
from sewer-gas — Cases illustrating this mode of infection — Contagion from 
other puerperal patients — Mode in which the poison may be conveyed to 
the patient — Conduct of the practitioner in relation to the disease — Nature 
of the septic poison — Local changes resulting from the absorption of septic 
material — Channels through which systemic infection is produced — 
Pathological phenomena observed after general blood-infection — Four 
principal types of pathological change — Intense cases without marked 
post-mortem signs— Cases characterized by inflammation of the serous 
membranes — Cases characterized by the impaction of infected emboli, and 
secondary inflammation and abscess — Description of the disease — Duration 
— Varieties of symptoms in different cases — Symptoms of local complica- 
tions — Treatment 623 

CHAPTER VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal thrombosis and its results — Conditions which favor thrombosis — 
Conditions which favor coagulation in the puerperal state — Distinction 
between thrombosis and embolism — Is primary thrombosis of the pulmo- 
nary arteries possible ? — History — Symptoms of pulmonary obstruction — 
Is recovery possible? — Causes of death— Post-mortem appearances— Treat- 
ment — Puerperal pleuro-pneumonia : its causes and treatment . . . 656 



CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

Causes — Symptoms — Treatment 



CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE 
PUERPERAL STATE. 

Organic and functional causes — Idiopathic asphyxia — Pulmonary apoplexy — 
Cerebral apoplexy — Syncope — Shock and exhaustion — Entrance of air into 
the veins 670 



XX CONTENTS. 



CHAPTER IX. 



PERIPHERAL VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS— PHLEGMASIA 
DOLENS — ANASARCA SEROSA — OZDEMA LACTEUM — WHITE LEG, ETC.) 

PAGE 

Nature — Symptoms — History and pathology — [Crural phlebitis after Csesarean 
and Porro operations] — Anatomical form of the thrombi in the veins — 
Detachment of emboli — Treatment 673 



CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Two forms of inflammatory disease met with after labor — Variety of nomen- 
clature — Importance of differential diagnosis — Etiology — Connection with 
septicaemia — Seat of inflammation — Relative frequency of the two forms of 
disease — Symptomatology — Results of physical examination — Terminations 
— Prognosis — Treatment .......... 680 



Index 689 



PLATE 



V. Cava Inf. 



Pleura 



L. Renal Y. 




Os Pubis 



Bladder- 



Clitoris 



SECTION OF A FROZEN BODY IN THE LAST MONTH OF PREGNANCY (AFTEK BRATJNE), ILLUSTRATING THE 

RELATIONS OF THE UTERUS TO THE SURROUNDING PARTS, AND THE ATTITUDE OF THE 

FOETUS, WHICH IS LYING IN THE SECOND CRANIAL POSITION. 



PLATE I I 



Pancreas 



?tomacl 



— Coeliac A. 

-Sup. Meson t. A 
— V.PortaB 

_Lefi Ben. V. 



I_ Desc. Aorta, 



— Duodenum 




in: 



Ext. 03 Uteri 



Urethra 



Ext. Os Utori 



Rectum 



Liquor Amnii 



«ECTION OF A FROZEN BODY AT THE TERMINATION OF THE FIRST STAGE OF LABOR (AFTER BRAUN1 
THE BAG OF MEMBRANES IS STILL I'NBROKEN, THE CERVIX IS FULLY DILATED, AND 
TIIF. HEAD IN THE SECOND POSITION) IS IN THE PELVIC CAVITY. 



THE SCIENCE AND PRACTICE 



OF 



MIDWIFERY. 



PART I. 



ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 

IN PARTURITION. 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

The pelvis is the bony basin situated between the trunk and the 
lower extremities. To the obstetrician its study is of paramount 
importance ; for it not only contains, in the unimpregnated state, all 
the organs connected with the function of reproduction, but through 
its cavity the foetus has to pass in the process of parturition. An 
accurate knowledge, therefore, of its anatomical formation may be 
said to be the very alphabet of obstetrics, without which no one can 
practise midwifery, either with satisfaction to himself or safety to his 
patient. 

In a treatise on obstetrics, however, any detailed account of the 
purely descriptive anatomy of the pelvis would be out of place. A 
knowledge of that must be taken for granted, and it is only necessary 
to refer to those points which have a more or less direct bearing on 
the study of its obstetrical relations. 

The pelvis is formed of four bones. On either side are the ossa in- 
nominata, joined together by the sacmtm ; to the inferior extremity of 
the sacrum is attached the coccyx, which is, in fact, its continuation. 

The os innominatum (Fig. 1) is an irregularly shaped bone 
originally formed of three distinct portions, the ilium, the ischium, 
and the pubes, which remain separated from each other up to and 
beyond the period of puberty. They are united at the acetabulum by 
a Y-shaped cartilaginous junction, which does not, as a rule, become 

3 



34 



ORGANS CONCERNED IN PARTURITION 



ossified until about the twentieth year. The consequence is that the 
pelvis, during the period of growth, is subject to the action of various 
mechanical influences to a far greater extent than in adult life ; and 
these, as we shall presently see, have an important effect in deter- 
mining the form of the bones. The external surface and borders of 
the os innominatum are chiefly of obstetric interest from giving attach- 
ment to muscles, many of which have an important accessory influence 
on parturition, such as the muscles forming the abdominal wall, which 
are attached to its crest, and those closing its outlet and forming the 
perineum, which are attached to the tuberosity of the ischium. On 
the anterior and posterior extremities of the crest of the ilium are 
two prominences (the anterior and posterior spinous processes) which 
are points from which certain measurements are sometimes taken. 
The internal surface of the upper fan-shaped portion of the os innomi- 
natum gives attachment to the iliacus muscle, and contributes to the 



FIG. 1. 




Os innominatum. 



support of the abdominal contents ; along with its fellow of the oppo- 
site side it forms the false pelvis. The false is separated from the true 
pelvis by the ilio-pectineal line, which, with the upper margin of the 
sacrum, forms the brim of the pelvis. This is of special obstetric 
importance, as it is the first part of the pelvic cavity through which 
the child passes, and that in which osseous deformities are most often 
met with. At one portion of the ilio-pectineal line, corresponding 
with the junction of the ilium and pubes, is situated a prominence, 
which is known as the ilio-pectineal eminence. 

The internal smooth surface of the innominate bone below the 
linea ilio-pectinea forms the greater portion of the pelvis proper. In 
front, with the corresponding portions of the opposite bone, it forms 
the arch of the pubes, under which the head of the child passes in 
labor. 

Behind this we observe the oval obturator foramen, and below that 
the tuberosity and spine of the ischium, the latter separating the great 



ANATOMY OF THE PELVIS. 



35 



Fig 2. 



and lessor sciatic notches, and giving attachment to ligaments of 
importance. The rough articulating surface posteriorly, by which the 

junction with the sacrum is effected, may be noted, and above this the 
prominence to which the powerful ligaments joining the sacrum and os 
innominatuin are attached. 

The sacrum (Fig. 2) is a triangular and somewhat spongy bone 
forming the continuation of the spinal column, and binding together 
the ossa innominata. It is originally 
composed of live 1 separate portions, anal- 
ogous to the vertebrae, which ossify and 
unite about the period of puberty, leaving 
on its internal surface four prominent 
ridges at the points of junction. The 
upper of these is sometimes so well 
marked as to be mistaken, on vaginal 
examination, for the promontory of the 
sacrum itself. 

The base of the sacrum is about 4J 
inches in width, and its sides rapidly 
approximate until they nearly meet at 
its apex, giving the whole bone a trian- 
gular or wedge shape. The anterior and 
posterior surfaces also approximate in 
the same way, so that the bone is much 
thicker at the base than at the apex. 
The sacrum, in the erect position of 
the body, is directed from above downward, and from before back- 
ward. At its upper edge it is joined, the lumbo-sacral cartilage inter- 
vening, with the fifth lumbar vertebra. The point of junction, called 
the promontory of the sacrum, is of great importance, as on its undue 
projection many deformities of the brim of the pelvis depend. The 
anterior surface of the bone is concave, and forms the curve of the 
sacrum ; more marked in some cases than in others. There is also 
more or less concavity from side to side. On it we observe four aper- 
tures on each side, the intervertebral foramina, giving exit to nerves. 
The posterior surface is convex, rough, and irregular, for the attach- 
ment of ligaments and muscles, and showing a ridge of vertical promi- 
nences corresponding to the spinous processes of the vertebra?. 

The sacrum is generally described as forming a keystone to the arch 
constituted by the pelvic bones, and transmitting the weight of the 
body, in consequence of its wedge-like shape, in a direction which 
tends to thrust it downward and backward, as if separating the ossa 
innominata. Dr. Duncan, 1 however, lias shown, from a careful con- 
sideration of its mechanical relations, that it should rather be regarded 
as a strong transverse beam, curved on its anterior surface, the extremi- 
ties of which are in contact with the corresponding articular surfaces 
of the ossa innominata. The weight of the body is thus transmitted 
to the innominate bones, and through them to the acetabula and the 




Sacrum and coccyx. 



1 Researches in Obstetrics, p. 67. 



36 ORGANS CONCERNED IN PARTURITION. 

femora (Fig. 3). There counter-pressure is applied, and the result is, 
as we shall subsequently see, an important modifying influence on the 
development and shape of the pelvis. 

The coccyx (Fig. 2) is composed of four small separate bones, 
which eventually unite into one, but not until late in life. The upper- 
most of these articulates with the apex of the sacrum. On its posterior 
surface are two small cornua, which unite with corresponding points at 
the tip of the sacrum. The bones of the coccyx taper to a point. To 
it are attached various muscles which have the effect of imparting con- 
siderable mobility. During labor, also, it yields to the mechanical 
pressure of the presenting part, so as to increase the antero-posterior 
diameter of the pelvic outlet to the extent of an inch or more. 

If, through disease or accident, as sometimes happens, the articular 
cartilages of the coccyx become prematurely ossified, the enlargement 
of the pelvic outlet during labor may be prevented, and considerable 
difficulty may thus arise. This is most apt to happen in aged prim- 
iparae, or in women who have followed sedentary occupations ; and 
not infrequently, under such circumstances, the bone fractures under 
the pressure to which it is subjected by the presenting part. 

Pelvic Articulations. — The pelvic bones are firmly joined together 
by various articulations and ligaments. The latter are arranged so as 
to complete the canal through which the foetus has to pass, and which 
is in great part formed by the bones. On its internal surface, where 
the absence of obstruction is of importance, they are everywhere 
smooth ; while externally, where strength is the desideratum, they 
are arranged in larger masses, so as to unite the bones firmly together. 
The pelvic articulations have been generally described as symphyses 
or amphiarthrodia, a term which is properly applied to two articulating 
surfaces, united by fibrous tissue in such a way as to prevent any 
sliding motion. It is certain, however, that this is not the case with 
the joints of the female pelvis during pregnancy and parturition. 
Lenoir found that in 22 females, between the ages of eighteen and 
thirty-five, there was a distinct sliding motion. .Therefore, the pelvic 
articulations are, strictly speaking, to be considered examples of the 
class of joints termed arthrodia. 

Lumbo-sacral Joint. — The last lumbar vertebra is united to the 
sacrum by ligamentous union similar to that which joins the vertebrae 
to each other. The intervening fibro-cartilage forms a disk, which is 
thicker in front than behind, and this, in connection with a similar 
peculiarity of the fifth lumbar vertebra, tends to increase the sloped 
position of the sacrum, and the angle which it forms with the vertebral 
column. It constitutes the most prominent portion of the promontory 
of the sacrum, and is the part on which the finger generally impinges 
in vaginal examinations. The anterior common vertebral ligament 
passes over the surface of the joints, and we also find the ligamenta 
subflava and the inter-spinous ligaments, as in the other vertebrae. 
The articular processes are joined together by a fibrous capsule, and 
there is also a peculiar ligament, the lumbo-sacral, extending from the 
transverse process of the vertebra on each side, and attaching itself to 
the sides of the sacrum and the sacro-iliac synchondrosis. 



ANATOMY OF THE PELVIS. 37 

Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, 
; n some cases at least, the separate bones of the coccyx to each other, 
by small cartilaginous disks like that connecting the sacrum with the 
last lumbar vertebra. They are further united by anterior and pos- 
terior common ligaments, the latter being much the thicker and more 
marked. In the adult female a synovial membrane is found between 
the sacrum and coccyx, and it is supposed that this is formed under 
the influence of the movements of the bones on each other. 

Sacro-iliac Synchondrosis. — The opposing articular surfaces of 
the sacrum and ilium are each covered by cartilages, that of the sacrum 
being the thicker. These are firmly united, but, in the female, accord- 
ing to Mr. Wood, 1 they are always more or less separated by an inter- 
vening synovial membrane. Posterior to these cartilaginous convex 
surfaces there are strong interosseous ligaments, passing directly from 
bone to bone, filling up the interspace between them, and uniting them 
firmly. There are also accessory ligaments, such as the superior and 
anterior sacro-iliac, which are of secondary consequence. The pos- 
terior sacro-iliac ligaments, however, are of great obstetric importance. 
They are the very strong attachments which unite the rough surfaces 
on the posterior iliac tuberosities to the posterior and lateral surfaces 
of the sacrum. They pass obliquely downward from the former 
points, and suspend, as it were, the sacrum from them. According to 
Duncan, the sacrum has nothing to prevent its being depressed by 
the weight of the body but these ligaments, and it is mainly through 
them that the weight of the body is transmitted to the sacro-cotyloid 
beams and the heads of the femora. 

The sacro -sciatic ligaments are instrumental in completing the 
canal of the pelvis. The greater sacro-sciatic ligament is attached by 
a broad base to the posterior inferior spine of the ilium, and to the 
posterior surfaces of the sacrum and coccyx. Its fibres unite into a 
thick cord, cross each other in an X-like manner, and again expand 
at their insertion into the tuberosity of the ischium. The lesser sacro- 
sciatic ligament is also attached with the former to the back parts of the 
sacrum and coccyx, its fibres passing to their much narrower insertion 
at the spine of the ischium, and converting the sacro-sciatic notch into 
a complete foramen. 

The obturator membrane is the fibrous aponeurosis that closes the 
large obturator foramen. Joulin 2 supposes that along with the sacro- 
sciatic ligaments, it may, by yielding somewhat to the pressure of the 
foetal head, tend to prevent the contusion to which the soft parts would 
be subjected if they Avere compressed between two entirelv osseous 
surfaces. 

Symphysis Pubis. — The junction of the pubic bones in front is 
effected by means of two oval plates of fibro-cartilage, attached to 
each articular surface by nipple-shaped projections, which fit into cor- 
responding depressions in the bones. There is a greater separation 
between the bones in front than behind, where the numerous fibres of 
the cartilaginous plates intersect, and unite the bones firmly together. 

1 Todd's Cyclopaedia ot Anatomy and Physiology, article " Pelvis," p. 123. 

2 Traite d'Accouchements, p. 11. 



38 



ORGANS CONCERNED IN PARTURITION 



At the upper and back part of the articulation there is an interspace 
between the cartilages, which is lined by a delicate membrane. In 
pregnancy this space often increases in size, so as to extend even to the 
front of the joint. The juncture is further strengthened by four liga- 
ments, the anterior, the posterior, the superior, and the sub-pubic. Of 
these, the last is the largest, connecting together the pubic bones and 
forming the upper boundary of the pubic arch. 



Fig. 3. 




Section of pelvis and heads of thigh-bones, showing the suspensory action of the sacro-iliac 
ligaments. (After Wood.) 

Movements of Pelvic Joints. — The close apposition of the bones 
of the pelvis might not unreasonably lead to the supposition that no 
movement took place between its component parts ; and this is the 
opinion which is even yet held by many anatomists. It is tolerably 
certain, however, that even in the unimpregnated condition there is a 
certain amount of mobility. Thus Zaglas has pointed out * that in man 
there is a movement in an antero-posterior direction of the sacro-iliac 
joints which has the effect, in certain positions of the body, of causing 
the sacrum to project downward to the extent of about a line, thus nar- 
rowing the pelvic brim, tilting up the point of the bone, and thereby 
enlarging the outlet of the pelvis. This movement seems habitually 
brought into play in the act of straining during defecation. 

During pregnancy in some of the lower animals there is a very 
marked movement of the pelvic articulations, which materially facili- 
tates the process of parturition. This, in the case of the guinea-pig 
and cow, has been especially pointed out by Dr. Matthews Duncan. 2 
In the former during labor the pelvic bones separate from each other 



1 Monthly Journal of Medical Science, Sept. 1851. 

2 Researches in Obstetrics, p. 19. 



ANATOMY OF THE PELVIS. 39 

to the extent of an inch or more. In the latter the movements are 
different, for the symphysis pn!>is is fixed by bony ankylosis, and is 
immovable; but the sacro-iliac joints become swollen during pregnancy, 
and extensive movements in an antero-posterior direction lake place 
in them, which materially enlarge the pelvic canal during labor. 

It is extremely probable that similar movements take place in 
women, both in the symphysis pubis and in the sacro-iliac joints, 
although to a less marked extent. These are particularly well described 
by Dr. Duncan. They seem to consist chiefly in an elevation and 
depression of the symphysis pubis, either by the ilia moving on the 
sacrum, or by the sacrum itself undergoing a forward movement on 
an imaginary transverse axis passing through it, thus lessening the 
pelvic brim to the extent of one or even two lines, and increasing, at 
the same time, the diameter of the outlet, by tilting up the apex of 
the sacrum. These movements are only an exaggeration of those 
which Zaglas describes as occurring normally during defecation. The 
positions which the parturient woman instinctively assumes find an 
explanation in these observations. During the first stage of labor, when 
the head is passing through the brim, she sits, or stands, or walks about, 
and in these erect positions the symphysis pubis is depressed, and the 
brim of the pelvis enlarged to its utmost. As the head advances 
through the cavity of the pelvis, she can no longer maintain her erect 
position, and she lies down and bends her body forward, which has 
the effect of causing a nutatory motion of the sacrum, with correspond- 
ing tilting up of its apex, and an enlargement of the outlet, 

These movements during parturition are facilitated by the changes 
which are known to take place in the pelvic articulations during preg- 
nancy- The ligaments and cartilages become swollen and softened, 
and the synovial membranes existing between the articulating surfaces 
become greatly augmented in size and distended with fluid. These 
changes act by forcing the bones apart, as the swelling of a sponge 
placed between them might do after it had imbibed moisture. The 
reality of these alterations receives a clinical illustration from those 
cases, which are far from uncommon, in which these changes are 
carried to so extreme an extent that the power of progression is 
materially interfered with for a considerable time after delivery. 

On looking at the pelvis as a whole, we are at once struck with its 
division into the true and false pelvis. The latter portion (all that is 
above the brim of the pelvis) is of comparatively little obstetric impor- 
tance, except in giving attachments to the accessory muscles of parturi- 
tion, and need not be further considered. The brim of the pelvis is a 
heart-shaped opening, bounded by the sacrum behind, the linea ilio- 
pectinea on either side, and the symphysis of the pubes in front. All 
below it forms the cavity, which is bounded by the hollow of the 
sacrum behind, by the inner surfaces of the innominate bones at the 
sides and in front, and by the posterior surface of the symphysis 
pubis. It is in this part of the pelvis that the changes in direction 
which the fetal head undergoes in labor are imparted to it. The lower 
border of this canal, or pelvic outlet (Fig. 4), is lozenge-shaped, is 
bounded by the ischiatic tuberosities on either side, the tip of the 



40 



ORGANS CONCERNED IN PARTURITION 



coccyx behind, and the under surface of the pubic symphysis in front. 
Posteriorly to the tuberosities of the ischia the boundaries of the outlet 
are completed by the sacro-sciatic ligaments. 



Fig. 4. 




Outlet of pelvis. 

There is a very marked difference between the pelvis in the male 
and the female, and the peculiarities of the latter all tend to facilitate 
the process of parturition. In the female pelvis (Fig. 5) all the bones 
are lighter in structure, and have the points for muscular attachments 
much less developed. The iliac bones are more spread out, hence the 
greater breadth which is observed in the female figure, and the pecu- 
liar side-to-side movement which all females have in walking. The 
tuberosities of the ischia are lighter in structure and farther apart, and 
the rami of the pubes also converge at a much less acute angle. This 
greater breadth of the pubic arch gives one of the most easily appreci- 
able points of contrast between the male and the female pelvis ; the 

Fig 5. 




The female pelvi?. 



pubic arch in the female forms an angle of from 90° to 100°, while 
in the male (Fig. 6) it averages from 70° to 75°. The obturator 
foramina are more triangular in shape. 



ANATOMY OF THE PELVIS. 41 

The whole cavity of the female pelvis is wider and less funnel- 
Bhaped than in the male, the symphysis pubis is not SO deep, and, as 
the promontory of tlio sacrum docs not project SO much, the shape of 
the pelvic brim is more oval than in the male. 'These differences 
between the male and female pelvis are probably due to the presence 

Fig. 6. 




The male pelvis. 



of the female genital organs in the true pelvis, the growth of which 
increases its development in width. In proof of this, Schroeder states 
that in women with congenitally defective internal organs, and in 
women who have had both ovaries removed early in life, the pelvis 
has always more or less of the masculine type. 



Fig. 




Brim of pelvis, showing antero-posterior, c. v, oblique, d, and transverse, t, diameters. 

Measurements of the Pelvis. — The measurements of the pelvis 
that are of most importance from an obstetric point of view are taken 
between various points directly opposite to each other, and are known 
as the diameters of the pelvis. Those of the true pelvis are the diam- 
eters which it is especially important to fix in our memories, and it is 
customary to describe three in works on obstetrics — the antero-posterior 



42 ORGANS CONCERNED IN PARTURITION. 

or conjugate, the oblique, and the transverse — although, of course, the 
measurements may be taken at any opposing points in the circumfer- 
ence of the bones. The antero-posterior (diameter Conjugata vera, 
c. v, sacro-pubie), at the brim (Fig. 7), is taken from the upper part of 
the posterior surface of the symphysis pubis to the centre of the promon- 
tory of the sacrum ; in the cavity, from the centre of the symphysis 
pubis to a corresponding point in the body of the third piece of the 
sacrum ; and at the outlet (coccy-pubic), from the lower border of the 
symphysis pubis to the tip of the coccyx. The oblique (diameter 
Diagonal is, d), at the brim, is taken from the sacro-iliac joint on either 
side to a point of the brim corresponding with the ilio-pectineal emi- 
nence — that starting from the right sacro-iliac joint being called the 
right oblique (diameter Diagonalis dextra, D. d), that from the left the 
left oblique (diameter Diagonalis sinistra, d. s) ; in the cavity a similar 
measurement is made at the same level as the conjugate ; while at the 
outlet an oblique diameter is not usually measured. The transverse 
(diameter Transversa, t) is taken, at the brim, from a point midway 
between the sacro-iliac joint and the ilio-pectineal eminence to a cor- 
responding point at the opposite side of the brim ; in the cavity, from 
points in the same plane as the conjugate and oblique diameters ; and 
at the outlet, from the centre of the inner border of one ischial tuber- 
osity to that of the other. The measurements given by various writers 
differ considerably and vary somewhat in different pelves. Taking the 
average of a large number, the following may be given as the standard 
measurements of the female pelvis : 

Anteroposterior, Oblique, Transverse, 

c. v. D. T. 

Inches. Inches. Inches. 

Brim 4.25 4.8 5.2 

Cavity 4.7 5.2 4.75 

Outlet 5.0 — 4.2 

It will be observed that the lengths of the corresponding diameters 
at different places vary greatly ; thus, while the transverse (t) is longest 
at the brim, the oblique (d) is longest in the cavity, and the antero- 
posterior (c. v) at the outlet. It will be subsequently seen that this 
fact is of great practical importance in studying the, mechanism of 
delivery, for the head in its descent through the pelvis alters its posi- 
tion in such a way as to adapt itself to the longest diameter of the 
pelvis ; thus, as it passes through the cavity it lies in the oblique (d) 
diameter, and then rotates so as to be expelled in the anteropos- 
terior (c. v) diameter of the outlet. 

In thinking of these measurements of the pelvis, it must not be 
forgotten that they are taken in the dried bones, and that they are 
considerably modified during life by the soft parts. This is especially 
the case at the brim, where the projection of the psoas and ijiacus 
muscles lessens the transverse (t) diameter about half an inch, while 
the antero-posterior (c. v) diameter of the brim, and all the diameters 
of the cavity, are lessened by a quarter of an inch. The right oblique 
diameter (d. d) of the brim is, even in the dried pelvis, found to be on 
an average slightly longer than the left (d. s), probably on account of 
the increased development of the right side of the pelvis from the greater 



ANATOMY OF THE PELVIS. 



43 



; Imt. in addition 
it Lessened durinj 
The 



to this, tli" left oblique 
; life by the pn - 






use made of the right lee 
diameter (d. - is Borneo b 
the rectum on the left side 
advantage gained by the com- 
paratively frequent passage of the 
head through the pelvis in the 
right oblique diameter (d. d) is 
thus explained. 

There are one or two other 
measurements of the true pelvis 
which are sometimes given, but 
which are of secondary impor- 
tance. One of these, the sacro- 
cotyloid diameter, is that between 
the promontory of the sacrum and 
a point immediately above the 
cotyloid cavity, and averages from 
3.4 to 3.5 inches. Another, called 
by Wood the lower or inelined 
conjugate diameter (diameter Con- 
jugate diagonally, C. D). is that be- 
tween the eentre of the lower mar- 
gin of the symphysis pubis and 
the promontory of the sacrum, and 
averages half an ineh more than 
the antero-posterior diameter of 
the brim [*]. These measurements 
are chiefly of importance in rela- 
tion to certain pelvic deformities. 

The external measurements of 
the pelvis are of no real conse- 
quence in normal parturition, but 
they may help us. in certain cases, 
to estimate the existence and 
amount of deformities. Those 
which are generally given are : Be- 
tween the anterior superior iliac 

spines, 10 inches; between the central points of the crests of the ilia, 
1< )h inches : between the spinous process of the last lumbar vertebra and 
the upper part of the symphysis pubis (external conjugate). 7 inches. 

Planes of the Pelvis. — By the planes of the pelvis are meant imagi- 
nary levels at any portion of its circumference. If we were to cut out 
a piece of cardboard so as to fit the pelvic cavity, and place it either at 
the brim or elsewhere, it would represent the pelvic plane at that par- 
ticular part, and it i- obvious that we may conceive as many planes as 
we desire. Observation of the angle which the pelvic planes form 
with the horizon -hows the great obliquity at which the pelvis is placed 
in regard to the spinal column. Thus the angle a b i (Fig. In repre- 




Section of pelvis, showing the diameters. 



P The c. d is frequently used in Continental reports, instead of the c. v.— Ed.] 



44 



ORGANS CONCERNED IN PARTURITION. 



sents the inclination to the horizon of the plane of the pelvic brim, i b, 
and is estimated to be about 60°, while the angle which the same plane 
forms with the vertebral column is about 150°. The plane of the out- 
let forms, with the coccyx in its usual position, an angle with the hori- 
zon of about 11°, but which varies greatly with the movements of the 
tip of the coccyx, and the degree to which it is pushed back during 
parturition. These figures must only be taken as giving an approxi- 
mate idea of the inclination of the pelvis to the spinal column, and it 



Fig. 




Planes of the pelvis with horizon, a b. Horizon, c d. Vertical line, a b i. Angle of inelina- 
nation of pelvis to horizon, equal to 60°. eic. Angle of inclination of pelvis to spinal column, 
equal to 150°. c u. Angle of inclination of sacrum to spinal column, equal to 130°. e f. Axis of 
pelvic inlet, l m. Mid-plane in the middle line. N. Lowest point of mid-plane of ischium. 

must be remembered that the degree of inclination varies considerably 
in the same female at different times, in accordance with the position 
of the body. During pregnancy especially, the obliquity of the brim 
is lessened by the patient throwing herself backward in order to sup- 
port more easily the weight of the gravid uterus. The height of the 
promontory of the sacrum above the upper margin of the symphysis 
pubis is, on an average, about three and three-quarters inches, and a 
line passing horizontally backward from the latter point would im- 
pinge on the junction of the second and third coccygeal bones. 

Axes of the Parturient Canal. — By the axis of the pelvis is meant 
an imaginary line which indicates the direction which the foetus takes 
during its expulsion. The axis of the brim (Fig. 10) is a line drawn 
perpendicular to its plane, which would extend from the umbilicus to 
about the apex of the coccyx ; the axis of the outlet of the bony pelvis 
intersects this, and extends from the centre of the promontory of the 
sacrum to midway between the tuberosities of the ischia. The axis of 



ANATOMY OF THE PELVIS, 
10. 



45 




/ \ 



\D 



Axe? of the pelvis, a. Axis of superior plane, b. Axis of mid-plane, c. Axis of inferior plane. 
d. Axis of canal, e. Horizon. 

the entire pelvic canal is represented by the sum of the axes of an 
indefinite number of planes at different levels of the pelvic cavity, 
which forms an irregular parabolic line, as represented in the accom- 
panying diagram (Fig. 10, a d). 

Fig. 11. 




Representing general axis of parturient canal, includiug the uterine cavity and soft parts. 



46 



ORGANS CONCERNED IN P ARTUKITION . 



It must be borne in mind, however, that it is not the axis of the 
bony pelvis alone that is of importance in obstetrics. We must always 
remember, in considering this subject, that the general axis of the par- 
turient canal (Fig. 11) also includes that of the uterine cavity above, 
and of the soft parts below. These are variable in direction according 
to circumstances ; and it is only the axis of that portion of the partu- 
rient canal extending between the plane of the pelvic brim and a plane 
between the lower edge of the pubic symphysis and the base of the 
cocteyx that is fixed. The axis of the lower part of the canal will vary 
according to the amount of distention of the perineum during labor ; 
but when this is stretched to its utmost, just before the expulsion of 
the head, the axis of the plane between the edge of the distended peri- 
neum and the lower border of the symphysis looks nearly directly for- 
ward. The axis of the uterine cavity generally corresponds with that 
of the pelvic brim, but it may be much altered by abnormal positions 
of the uterus, such as anteversion from laxity of the abdominal walls. 
The foetus, under such circumstances, will not enter the brim in its 
proper axis, and difficulties in labor arise. A knowledge of the gen- 
eral direction of the parturient canal 
fig. 12. is of great importance in practical 

midwifery in guiding us to the intro- 
duction of the hand or instruments in 
obstetric operations, and in showing 
us how to obviate difficulties arising 
from such accidental ^deviations of the 
uterus as have just been alluded to. 

Cavity of the Pelvis. — The arrange- 
ments of the bones in the interior of 
the pelvic canal (Fig. 12) are impor- 
tant in relation to the mechanism of 
delivery. A line passing between the 
spine of the ischium and the ilio-pec- 
tineal eminence divides the inner sur- 
face of the ischial bone into two smooth 
side view of pelvis. plane surfaces, which have received 

the name of the planes of the ischium. 
Two other planes are formed by the inner surfaces of the pubic bones 
in front and by the upper portion of the sacrum behind, both having 
a direction downward and backward. In studying the mechanism of 
delivery, it will be seen that many obstetricians attribute to these 
planes, iD conjunction with the spines of the ischia, a very important 
influence in effecting rotation of the foetal head from the oblique to the 
antero-posterior diameter of the pelvis. 

Development of the Pelvis. — The peculiarities of the pelvis during 
infancy and childhood are of interest as leading to a knowledge of the 
manner in which the form observed during adult life is impressed upon 
it. The sacrum in the pelvis of the child (Fig. 13) is less developed 
transversely, and is much less deeply curved than in the adult. The 
pubes is also much shorter from side to side, and the pubic arch is an 
acute angle. The result of this narrowness of both the pubes and 




ANATOMY OF THE PELVIS. 47 

sacrum is that the transverse (t) diameter of the pelvic brim is shorter 
instead of longer than the antero-posterior (c. v). The sides of the 
pelvis have a tendency to parallelism, as well as the antero-posterior 
walls ; and this is stated by Wood to be a peculiar characteristic of the 
infantile pelvis. The iliac bones ;ire not spread out as in adult life, 
BO that the centres of" the crests of the ilia are not more distant from 
each other than the anterior superior spines. The cavity of the true 
pelvis is small, and the tuberosities of the ischia are proportionately 
nearer to each other than they afterward become; the pelvic viscera 
are consequently crowded up into the abdominal cavity, which is, for 
this reason, much more prominent in children than in adults. The 
bones arc soft and semi-cartilaginous until after the period of puberty, 
and yield readily to the mechanical influences to which they are 
subjected ; and the three divisions of the innominate bone remain 
separate until about the twentieth year. 

Fig. 13. 




Pelvis of a child. 



As the child grows older the transverse development of the sacrum 
increases, and the pelvis begins to assume more and more of the adult 
shape. The mere growth of the bones, however, is not sufficient to 
account for the change in the shape of the pelvis, and it has been well 
shown by Duncan that this is chiefly produced by the pressure to which 
the bones are subjected during early life. The iliac bones are acted 
upon by two principal and opposing forces. One is the weight of the 
body above, which acts vertically upon the sacral extremity of the 
iliac beam through the strong posterior sacro-iliac ligaments, and tends 
to throw the lower or acetabular ends of the sacro-cotyloid beams out- 
ward. This outward displacement, how r ever, is resisted, partly by the 
junction between the two acetabular ends at the front of the pelvis, 
but chiefly by the opposing force, which is the upward pressure of the 
lower extremities through the femurs. The result of these counteract- 
ing forces is that the still soft bones bend near their junction with 
the sacrum, and thus the greater transverse development of the pelvic 
brim characteristic of adult life is established. In treating of pelvic 



48 ORGANS CONCERNED IN PARTURITION. 

deformities it will be seen that the same forces applied to diseased and 
softened bones explain the peculiarities of form that they assume. 

Pelvis in Different Races. — The researches that have been made 
on the differences of the pelvis in different races prove that these are 
not so great as might have been expected. Joulin pointed out that in 
all human pelves the transverse (t) diameter was larger than the 
antero-posterior (c. v), while the reverse was the case in all the lower 
animals, even in the highest simiae. This observation has been more 
recently confirmed by Von Franque, 1 who has made careful measure- 
ments of the pelvis in various races. In the pelvis of the gorilla the 
oval form of the brim, resulting from the increased length of the 
conjugate (c. v) diameter, is very marked. In certain races there is 
so far a tendency to animality of type that the difference between the 
transverse (t) and conjugate (c. v) diameters is much less than in 
European women, but it is not sufficiently marked to enable us to 
refer any given pelvis to a particular race. Von Franque makes the 
general observation that the size of the pelvis increases from south to 
north, but that the conjugate (c. v) diameter increases in proportion to 
the transverse (t) in southern races. 

Soft Parts in Connection -with Pelvis. — In closing the description 
of the pelvis, the attention of the student must be directed to the 
muscular and other structures which cover it. It has already been 
pointed out that the measurements of the pelvic diameters are con- 
siderably lessened by the soft parts, which also influence parturition 
in other ways. Thus, attached to the crests of the ilia are strong 
muscles which not only support the enlarged uterus during pregnancy, 
but are powerful accessory muscles in labor : in the pelvic cavity are 
the obturator and pyriformis muscles lining it on either side ; the 
pelvic cellular tissue and fascia? ; the rectum and bladder ; the vessels 
and nerves, pressure on which often gives rise to cramps and pains 
during pregnancy and labor ; while below, the outlet of the pelvis is 
closed, and its axis directed forward by the numerous muscles forming 
the floor of the pelvis and perineum. The structures closing the 
pelvis have been accurately described by Dr. Berry Hart, 2 who points 
out that they form a complete diaphragm stretching from the pubis to 
the sacrum, in which are three " faults " or "slits" formed by the 
orifices of the urethra, vagina, and rectum. The first of these is a 
mere capillary slit, the last is closed by a strong muscular sphincter, 
while the vagina, in a healthy condition, is also a mere slit, with its 
walls in accurate apposition. Hence it follows that none of these 
apertures impairs the structural efficiency of the pelvic floor, or the 
support it gives to the structures above it. 

Scanzoni's Beitrage, 1867. 

The Structural Anatomy of the Female Pelvic Floor. 



THE FEMALE GENERATIVE ORGANS. 49 



CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

The reproductive organs in the female are conveniently divided, 
according to their function, into: 1. The external or copulative organs, 
which are chiefly concerned in the act of insemination, and are only 
of secondary importance in parturition : they include all the organs 
situate externally which form the vulva ; and the vagina, which is 
placed internally and forms the canal of communication between the 
uterus and the vulva. 2. The internal or formative organs : they 
include the ovaries, which are the most important of all, as being 
those in which the ovule is formed; the Fallopian tubes, through 
which the ovule is carried to the uterus ; and the uterus, in which the 
impregnated ovule is lodged and developed. 

1. The external organs consist of: 

The mons Veneris (Fig. 14, f), a cushion of adipose and fibrous 
tissue which forms a rounded projection at the upper part of the vulva. 
It is in relation above with the lower part of the hypogastric region, 
from which it is often separated by a furrow, and below it is con- 
tinuous Avith the labia majora on either side. It lies over the sym- 
physis and horizontal rami of the pubes. After puberty it is covered 
with hair. On its integument are found the openings of numerous 
sweat and sebaceous glands. 

The labia majora (Fig. 14, a) form two symmetrical sides to the 
longitudinal aperture of the vulva. They have two surfaces, one 
external, of ordinary integument, covered with hair, and another 
internal, of smooth mucous membrane, in apposition with the corre- 
sponding portion of the opposite labium, and separated from the 
external surface by a free convex border. They are thicker in front, 
where they run into the mons Veneris, and thinner behind, where they 
are united, in front of the perineum, by a thin fold of integument 
called the fourchette, which is almost invariably ruptured in the first 
labor. In the virgin the labia are closely in apposition, and conceal 
the rest of the generative organs. After childbearing they become 
more or less separated from each other, and in the aged they waste, 
and the internal nymphse protrude through them. Both their cuta- 
neous and mucous surfaces contain a large number of sebaceous glands, 
opening either directly on the surface or into the hair follicles. In 
structure the labia are composed of connective tissue, containing a 
varying amount of fat, and parallel with their external surface are 
placed tolerably close plexuses of elastic tissue, interspersed with 
regularly arranged smooth muscular fibres. These fibres are described 
by Broca as forming a membranous sac, resembling the dartos of the 
scrotum, to which the labia majora are analogous. Toward its upper 

4 



50 



ORGANS CONCERNED IN PARTURITION 



and narrower end this sac is continuous with the external inguinal 
ring, and in it terminate some of the fibres of the round ligament. 
The analogy with the scrotum is further borne out by the occasional 
hernial protrusion of the ovary into the labium, corresponding to the 
normal descent of the testis in the male. 



Fig. 14. 




laws: 




External genitals of virgin with diaphragmatic hymen, a. Labium majus. b. Labium minus. 
c. Praeputium clitoridis. d. Glans clitoridis. e. Vestibule just above urethral orifice, f. Mons 
Veneris. (After Sappey.) 



The labia minora, or nymphae (Fig. 14, 6), are two folds of 
mucous membrane, commencing below, on either side, about the centre 
of the internal surface of the labium externum ; they converge as they 
proceed upward, bifurcating as they approach each other. The lower 
branch of this bifurcation is attached to the clitoris (Fig. 14, d), while 
the upper and larger unites with its fellow of the opposite side, and 
forms a fold round the clitoris, known as its prepuce, c. The nymphae 
are usually entirely concealed by the labia majora, but after child- 
bearing and in old age they project somewhat beyond them ; then they 
lose their delicate pink color and soft texture, and become brown, dry, 
and like skin in appearance. This is especially the case in some of 
the negro races, in whom they form long projecting folds called the 
apron. 



THE FEMALE GENERATIVE ORGANS. 51 

The surfaces of the nymphse arc covered with tessellated epithelium, 
and over them are distributed a large number of vascular papillae, 
somewhat enlarged at their extremities, and sebaceous glands, which 
are more numerous on their internal surfaces. The latter secrete an 
odorous, cheesy matter, which lubricates the surface of the vulva, and 
prevents its folds adhering to each other. The nymphse are composed 
of trabecule of connective tissue, containing muscular fibres. 

The clitoris (Fig. 14, d) is a small erectile tubercle situated about 
half an inch below the anterior commissure of the labia majora. It 
is the analogue of the penis in the male, and is similar to it in struc- 
ture, consisting of two corpora cavernosa, separated from each other 
by a fibrous septum. The crura are covered by the ischio T caveraous 
muscles, which serve the same purpose as in the male. It has also a 
suspensory ligament. The corpora cavernosa are composed of a vas- 
cular plexus with numerous traversing muscular fibres. The arteries 
are derived from the internal pudic artery, which gives a branch, the 
cavernous, to each half of the organ ; there is also a dorsal artery dis- 
tributed to the prepuce. According to Gussenbauer, these cavernous 
arteries pour their blood directly into large veins, and a finer venous 
plexus near the surface receives arterial blood from small arterial 
branches. By these arrangements the erection of the organ which 
takes place during sexual excitement is favored. The nervous supply 
of the clitoris is large, being derived from the internal pudic nerve, 
which supplies branches to the corpora cavernosa, and terminates in 
the glans and prepuce, where Paccinian corpuscles and terminal bulbs 
are to be found. On this account the clitoris has been supposed by 
some to be the chief seat of voluptuous sensation in the female. 

The vestibule (Fig. 14, e) is a triangular space, bounded at its apex 
by the clitoris, and on either side by the folds of the nymphae. It is 
smooth, and, unlike the rest of the vulva, is destitute of sebaceous 
glands, although there are several groups of muciparous glands open- 
ing on its surface. At the centre of the base of the triangle, which is 
formed by the upper edge of the opening of the vagina, is a promi- 
nence, distant about an inch from the clitoris, on which is the orifice 
of the urethra. This prominence can be readily made out by the 
finger, and the depression upon it — leading to the urethra — is of im- 
portance as our guide in passing the female catheter. This little 
operation ought to be performed without exposing the patient, and 
it is done in several ways. The easiest is to place the tip of the index 
finger of the left hand (the patient lying on her back) on the apex of 
the vestibule, and slip it gently down until we feel the bulb of the 
urethra, and the dimple of its orifice, which is generally readily found. 
If there is any difficulty in finding the orifice, it is well to remember 
that it is placed immediately below the sharp edge of the lower border 
of the symphysis pubis, which will guide us to it. The catheter (and 
a male elastic catheter is always the best, especially during labor, when 
the urethra is apt to be stretched) is then passed under the thigh of the 
patient, and directed to the orifice of the urethra by the finger of the 
left hand, which is placed upon it. We must be careful that the 
instrument is really passed into the urethra, and not into the vagina. 



52 ORGANS CONCERNED IN PARTURITION. 

It is advisable to have a few feet of elastic tubing attached to the end 
of the catheter, so that the urine can be passed into a vessel under the 
bed without uncovering the patient. If the patient be on her side, in 
the usual obstetric position, the operation can be more readily per- 
formed by placing the tip of the finger in the vagina, and feeling its 
upper edge. The orifice of the urethra lies immediately above this, 
and if the catheter be slipped along the palmar surface of the finger, it 
can generally be inserted without much trouble. If, however, as is 
often the case during labor, the parts are much swollen, it may be diffi- 
cult to find the aperture, and it is then always better to look for the 
opening than to hurt the patient by long-continued efforts to feel it. 

The urethra is a canal one and a half inches in length, and it is 
intimately connected with the anterior wall of the vagina, through 
which it may be felt. It is composed of muscular and erectile tissue, 
and is remarkable for its extreme dilatability, a property which is 
turned to practical account in some of the operations for stone in the 
female bladder. 

About an eighth of an inch above its orifice are the openings of two 
glandular structures situated in its muscular walls. They are about 
three-quarters of an inch in length, and were first described by Pro- 
fessor Skene, of Brooklyn. 1 

The orifice of the vagina is situated immediately below the bulb 
of the urethra. In virgins it is a circular opening, but in women who 
have borne children or practised sexual intercourse it is, in the undis- 
tended state, a fissure, running transversely, and at right angles to that 
between the labia. 2 In virgins it is generally more or less blocked up 
by a fold of mucous membrane, containing some cellular tissue and 
muscular fibres, with vessels and nerves, which is known as the hymen. 
This is continuous with the anterior extremity of the vagina, the 
mucous membrane of which lines its internal surface ; that covering 
its external surface being derived from the mucous membrane of the 
vulva. 3 The hymen is developed late in the female embryo, and at 
first is seen in the form of two projections on either side of the uro- 
genital fissure, which ultimately unite in the central line. At birth it 
is very prominent, and has occasionally been taken for the internal 
labia. 4 It is most often crescentic in shape, with the concavity of the 
crescent looking upward ; sometimes, however, it is circular with a 
central opening, or cribriform ; or it may even be entirely imperforate, 
and this gives rise to the retention of the menstrual secretion. These 
varieties of form depend on the peculiar mode of development of the 
fold of vaginal mucous membrane which blocks up the orifice of the 
vagina in the foetus, and from which the hymen is formed. The density 
of the membrane also varies in different individuals. Most usually 
it is very slight, so as to be ruptured in the first sexual approaches, 
or even by some accidental circumstance, such as stretching the limbs, 
so that its absence cannot be taken as evidence of want of chastity. 
A knowledge of this fact is of considerable importance from a medico- 

1 A.mer. Journ. of Obstetrics, 1880, vol. xiii. p. 265. 2 Hart : op. cit. 

3 Budin : Rechercb.es sur l'Hymen et l'Orifice vaginal, 1879. 

4 Doran : Gynecological Operations, p. 7. 



THE FEMALE GENERATIVE ORGANS. 53 

legal point of view. Sometimes it is so tough as to prevent inter- 
course altogether, and may require division by the knife or scissors 
before this can be effected; and at others it rather unfolds than rup- 
tures, so that it may exist even after impregnation has been effected, 
and it has been met with intact in women who have habitually led 
unchaste lives. In a few rare cases it has even formed an obstacle to 
delivery, and has required incision during labor. 

The carunculae myrtiformes are small fleshy tubercles varying 
from two to five in number, situated round the orifice of the vagina, 
and which are generally supposed to be the remains of the ruptured 
hymen. Schroeder, however, maintains that they are only formed 
after childbearing, in consequence of parts of the hymen having been 
destroyed by the injuries received during the passage of the child. 

Vulvovaginal Glands. — Near the posterior part of the vaginal 
orifice, and below the superficial perineal fascia, are situated two con- 
glomerate glands which are the analogues of Cowper's glands in the male. 
Each of these is about the size and shape of an almond, and is contained 
in a cellular fibrous envelope. Internally they are of a yellowish - 
white color, and are composed of a number of lobules separated from 
each other by prolongations of the external envelope. These give origin 
to separate ducts which unite into a common canal, about half an inch 
in length, which opens in front of the attached edge of the hymen in 
virgins, and in married women at the base of one of the carunculae 
myrtiformes. According to Huguier, the size of the glands varies 
much in different women, and they appear to have some connection 
with the ovary, as he has always found the largest gland to be on the 
same side as the largest ovary. They secrete a glairy, tenacious fluid, 
which is ejected in jets during the sexual orgasm, probably through 
the spasmodic action of the perineal muscles. At other times their 
secretion serves the purpose of lubricating the vulva, and thus pre- 
serves the sensibility of its mucous membrane. 

Fossa Navicularis. — Immediately behind the hymen in the unmar- 
ried, and between it and the perineum, is a small depression, called the 
fossa navicularis, which disappears after childbearing. 

The perineum separates the orifice of the vagina from that of the 
rectum. It is about one and a half inches in breadth, and is of great 
obstetric interest, not only as supporting the internal organs from 
below, but because of its action in labor. It is largely stretched and 
distended by the presenting part of the child, and, if unusually tough 
and unyielding, may retard delivery, or it may be torn to a greater or 
less extent, thus giving rise to various subsequent troubles. 

Vascular Supply of the Vulva. — The structures described above 
together form the vulva, and they are remarkable for their abundant 
vascular and nervous supply. The former constitutes an erectile tissue, 
similar to that which has already been described in the clitoris, and 
which is specially marked about the bulb of the vestibule. From 
this point, and extending on either side of the vagina, there is a well- 
marked plexus of convoluted veins (Fig. 15, a), which, in their dis- 
tended state, arc likened by Dr. Arthur Farre to a filled leech. The 
distention of the erectile tissue, as well as that of the clitoris, is brought 



54 



ORGANS CONCERNED IN PARTURITION 



about under excitement, as in the male, by the compression of the 
efferent veins, by the contraction of the ischio-cavernous muscles, and 
by that of a thin layer of muscular tissues surrounding the orifice of the 
vagina, and described as the constrictor vaginae. 



Fig. 15. 




Vascular supply of vulva, a. Plexus of convoluted veins (or "the bulb"), b. Muscular tissue 
of vagina, c, d, e,f. The clitoris (/) and muscles, g, h. i, k, I, m, n. Veins of the nymphse and 
clitoris communicating with the epigastric and obturator veins. (After Kobelt.) 



The vagina is the canal which forms the communication between 
the external and internal generative organs, through which the semen 
passes to reach the uterus, the menses flow, and the foetus is expelled. 
Roughly speaking, it lies in the axis of the pelvis, but its opening is 
placed anterior to the axis of the pelvic outlet, so that its loAver j>ortion 
is curved forward, so as to lie parallel to the pelvic brim. It is narrow 
below, but dilated above, where the cervix uteri is inserted into it, so 
that it is more or less conoidal in shape. Under ordinary circum- 
stances, especially in the virgin, the anterior and posterior walls lie in 
close contact with each other (see Plate I.), and there is, strictly speak- 
ing, no vaginal canal, although they are capable of wide distention, as 
in copulation, and during the passage of the foetus. The anterior wall 
of the vagina is shorter than the posterior, the former measuring on an 
average two and a half inches, the latter three inches ; but the length 
of the canal varies greatly in different subjects and under certain cir- 
cumstances. In front the vagina is closely connected with the base of 
the bladder, so that when the vagina is prolapsed, as often occurs, it 
drags the bladder with it (Fig. 17) ; behind, it is in relation with the 
rectum, but less intimately ; laterally, with the broad ligaments and 
pelvic fascia ; and superiorly, with the lower portion of the uterus and 



THE FEMALK GENERATIVE ORGANS. 



55 



folds of peritoneum both before and behind. The vagina is composed 
of mucous, muscular, and cellular coat-. The mucous Lining is thrown 
into numerous folds. These start from Longitudinal ridges which exist 
on I >« >t 1 1 the anterior and posterior walls, but most distinctly on the 
anterior. They are very numerous in the young and unmarried, and 
greatly increase the sensitive surface of the vagina (Fig. 16). After 
childbearing, and in the aged, they become atrophied, but they never 
completely disappear, and toward the orifice of the vagina, when- they 
exist in greatest abundance, they are always to be met with. The 
whole of the mucous membrane is lined with tessellated epithelium, 
and it is covered with a large number of papillae, either conical or 
divided, which are highly vascular and project into the epithelial layer. 
Unlike the vulvar mucous membrane, that of the vagina seems t«» be 

Fig. 16. 




Right half of virgin vagina, with walls held apart, showing the abundant transverse rugse, the 
greater depth of the vagina above than below, and the hymeneal segment. After Hart. 



destitute of glands. Beneath the epithelial layer is a submucous tissue 
containing a large number of elastic and some muscular fibres, derived 
from the muscular walls of the vagina. These are strong and well de- 
veloped, especially toward the ostium vagina?, where they are arranged 
in a circular mass, having a sphincter action. They consist of two 
layers — an internal longitudinal, and an external circular — with oblique 
decussating fibres connecting the two. Below they are attached to the 
ischio-pubic rami, and above they are continuous with the muscular 
coat of the uterus. The muscular tissue of the vagina increase 9 
thickness during pregnancy, but to a much less degree than that of the 
uterus. Its vascular arrangements, like those of the vulva, are such 
a- to constitute an erectile tissue. The arteries form an intricate net- 
work around the tube, and eventually end in a submucous capillary 
plexus from which twigs pa— t<> supply the papillae ; these, again, give 
origin to venous radicle- which unit*' into meshes freely interlacing 
with each other, and forming a well-marked venous plexus. 



56 



ORGANS CONCERNED IN PARTURITION, 



Ftg. 17. 




Longitudinal section of body, showing relations of generative organs. 



Fig. 18. 




Transverse section of the body, showing relations of the fundus uteri, m. Pubes. a a (in front). 
Remainder of hypogastric arteries, a a (bebind). Spermatic vessels and nerves. B. Bladder. 
L L. Round ligaments. U. Fundus uteri. 1 1. Fallopian tubes, o o. Ovaries, r. Rectum, 
g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v. Last lumbar vertebra. 



THE FEMALE GENERATIVE ORGANS. 57 

2. The internal organs of generation consist of the uterus, the Fallo- 
pian tubes, and the ovaries; and in connection with them we have to 
study the various Ligaments and folds of peritoneum which serve to 
maintain the organs in position, along with certain accessory struc- 
tures. Physiologically, the most important of all the generative organs 
are the ovaries, in which the ovules are formed, and which dominate 
the entire reproductive life of the female. The Fallopian tubes, which 
convey the ovule to the uterus, and the uterus itself — whose main 
function is to receive, nourish, and eventually expel the impregnated 
product of the ovary — may he said to he, in fact, accessory to these 
viscera. Practically, however, as obstetricians, we are chiefly con- 
cerned with the uterus, and may conveniently commence with its 
description. 

The uterus is correctly described as a pyriform organ, flattened 
from before backward, consisting of the body, with its rounded fundus, 
and the cervix, which projects into the 'upper part of the vaginal canal. 
In the adult female it is deeply situated in the pelvis, being placed 
between the bladder in front and the rectum behind, its fundus being 
below 7 the plane of the pelvic brim (Fig. 18). It only assumes this 
position, however, toward the period of puberty ; and in the foetus it 
is placed much higher, and lies, indeed, entirely within the cavity of 
the abdomen. It is maintained in this position partly by being slung 
by its ligaments, which we shall subsequently study, and partly by 
being supported from below 7 by the pelvic cellular tissue and the fleshy 
column of the vagina. The result is that the uterus, in the healthy 
female, is a perfectly movable body, altering its position to suit the 
condition of the surrounding viscera, especially the bladder and rectum, 
which are subjected to variations of size according to their fulness or 
emptiness. When from any cause the mobility of the organ is inter- 
fered with — as, for example, by some peri-uterine inflammation produ- 
cing adhesions to the surrounding textures — much distress ensues, and 
if pregnancy supervenes more or less serious consequences may result. 
Generally speaking, the uterus may be said to lie in a line roughly 
corresponding with the axis of the pelvic brim, its fundus being- 
pointed forward and its cervix lying in such a direction that a line 
drawn from it would impinge on the junction between the sacrum and 
coccyx. According to some authorities, the uterus in early life is more 
curved in the anterior direction, and is, in fact, normally in a state of 
anteflexion. Sappey holds that this is not necessarily the ease, but 
that the amount of anterior curvature depends on the emptiness or 
fulness of the bladder, on which the uterus, as it were, moulds itself 
in the unimpregnated state. It is believed also that the body of the 
uterus is very generally twisted somewhat obliquely, so that its anterior 
surface looks a little toward the right side, this probably depending 
on the presence and frequent distention of the rectum in the left side 
of the pelvis. The anterior surface of the uterus is convex, and is 
covered in three-fourths of its extent by the peritoneum which is inti- 
mately adherent to it. Below r the reflection of the membrane it is 
loosely connected by cellular tissue to the bladder, so that any down- 
ward displacement of the uterus drags the bladder along with it. The 



58 



ORGANS CONCERNED IN PARTURITION. 



posterior surface is also convex, but more distinctly so than the anterior, 
.as may be observed in looking at a transverse section of the organ 
(Fig. 19). It is also covered by peritoneum, the reflection of which 
on the rectum forms the cavity known as Douglas's pouch. The 
fundus is the upper extremity of the uterus, lying above the points of 
entry of the Fallopian tubes. It is only slightly rounded in the 



Fig. 19. 




Transverse section of uterus. 

virgin, but becomes more decidedly and permanently rounded in the 
woman who has borne children. 

Until the period of puberty the uterus remains small and unde- 
veloped (Fig. 20) ; after that time it reaches the adult size, at which it 
remains until menstruation ceases, when it again atrophies. If the 
woman has borne children, it always remains larger than in the 

Fig. 20. 




Uterus and appendages in an infant. (After Farre.) 



nullipara. In the virgin adult the uterus measures 2J inches from 
the orifice to the fundus, rather more than half being taken up by the 
cervix. _ Its greatest breadth is opposite the insertion of the Fallopian 
tubes; its greatest thickness, about 11 or 12 lines, opposite the centre 
of its body. Its average weight is about 9 or 10 drachms. Indepen- 



THE FEMALE GENERATIVE ORGANS 59 

dently of pregnancy, the uterus is subject to great alterations of size 
toward the menstrual period, when, on account of the congestion then 
present, it enlarges — sometimes, it is said, considerably. This fact 
should be borne in mind, as this periodical swelling might be taken 
for an early pregnancy. 

For the purpose of description the uterus is conveniently divided into 
the fundus, with its rounded upper extremity, situated between the in- 
sertions of the Fallopian tubes; the body, which is bounded above by 
the insertions of the Fallopian tubes, and below by the upper extremity 
of the cervix, and which is the part chiefly concerned in the reception 
and growth of the ovum ; and the cervix, which projects into the vagina, 
and dilates during labor to give passage to the child. The cervix is 
conical in shape, measuring 11 to 12 lines transversely at the base, 
and 6 or 7 in the antero-posterior direction ; while at the apex it 
measures 7 to 8 transversely, and 5 antero-posteriorly. It projects 
about 4 lines into the canal of the vagina, the remainder of the cervix 
being placed above the reflection of the vaginal mucous membrane. 
It varies much in form in the virgin and nulliparous married woman, 
and in the woman who has borne children ; and the differences are of 
importance in the diagnosis of pregnancy and uterine disease. In the 
virgin it is regularly pyramidal in shape. At its lower extremity is 
the opening of the external os uteri, forming a small circular opening, 
sometimes difficult to feel, and generally described as giving a sensa- 
tion to the examining finger like the extremity of the cartilage at the 
tip of the nose. It is bounded by two lips, the anterior of which is 
apparently larger on account of the position of the uterus. The sur- 
face of the cervix and the borders of the os are very smooth and 
regular. 

In women who have borne children these parts become considerably 
altered. The cervix is no longer conical, but is irregular in form and 
shortened. The lips of the os uteri become fissured and lobulated, on 
account, of partial lacerations which have occurred during labor. The 
os is larger and more irregular in outline, and is sometimes sufficiently 
patulous to admit the tip of the finger. In old age the cervix atro- 
phies, and after the change of life it not uncommonly entirely dis- 
appears, so that the orifice of the os uteri is on a level with the roof 
of the vagina. 

The internal surface of the uterus comprises the cavities of the body 
and cervix — the former being rather less than the latter in length in 
virgins, but about equal in Avomen who have borne children — separated 
from each other by a constriction forming the upper boundary of the 
cervical canal. The cavity of the body is triangular in shape, the base 
of the triangle being formed by a line joining the openings of the 
Fallopian tubes, its apex by the upper orifice of the cervix, or internal 
os, as it is sometimes called. In the virgin its boundaries are some- 
what convex, projecting inward. After childbearing they become 
straight or slightly concave. The opposing surfaces of the cavity are 
always in contact in the healthy state, or are only separated from each 
other by a small quantity of mucus. 

The cavity of the cervix is spindle-shaped or fusiform, narrower 



60 



ORGANS CONCERNED IN PARTURITION. 



above and below, at the internal and external os uteri, and somewhat 
dilated between these two points. It is flattened from before back- 
ward, and its opposing surfaces also lie in contact, but not so closely 
as those of the body. On the mucous lining of the anterior and pos- 
terior surfaces is a prominent perpendicular ridge, with a lesser one at 
each side, from which transverse ridges proceed at more or less acute 
angles. They have received the name of the arbor vitce. According 
to Guvon, the perpendicular ridges are not exactly opposite, so that 
they fit into each other, and serve more completely to fill up the cavity 
of the cervix, especially toward the internal os (Fig. 21). The arbor 
vita? is most distinct in the virgin, and atrophies considerably after 



childbearing. 



Fig. 21. 




Portion of interior of cervix. (Enlarged nine diameters.) (After Tvler Smith and Hassall.) 



The superior extremity of the cervical canal forms a narrow isthmus 
separating it from the cavity of the body, and measuring about three- 
eighths of an inch in diameter. Like the external os, it contracts after 
the cessation of menstruation, and in old age sometimes becomes en- 
tirely obliterated. 

The uterus is composed of three principal structures — the peritoneal, 
muscular, and mucous coats. The peritoneum forms an investment to 
the greater part of the organ, extending downward in front to the 
level of the os internum, and behind to the top of the vagina, from which 
points it is reflected upward on the bladder and rectum respectively. 
At the sides the peritoneal investment is not so extensive, for a little 
below the level of the Fallopian tubes the peritoneal folds separate 
from each other, forming the broad ligaments (to be afterward de- 
scribed) ; here it is that the vessels and nerves supplying the uterus 



THE FEMALE GENERATIVE (MUJANS. 



(>1 



gain access to it. At the upper part 
SO closely adherent to the muscular ti 
from it ; below the connection is more 
tissue, both in the body and cer- 
vix, consists of unstriped muscu- 



'I the organ the peritoneum is 

jsue that it cannol be separated 

loose. The mass of the uterine 
Fig. 22. 




lar fibres (Fig. 22), firmly united 
together by nucleated connective 

tissue and elastic fibres. The mus- 
cular fibre cells are large and fusi- 
form, with very attenuated extremi- 
ties, generally containing in their 
centre a distinct nucleus. These 
cells, as well as their nuclei, become 
greatly enlarged during pregnancy 
(Fig. 28); according to Strieker, 
this is only the case with the mus- 
cular fibres which play an important part in the expulsion of the 
foetus, those of the outermost and innermost layers not sharing in the 
increase of size. 1 In addition to these developed fibres there are, 
especially near the mucous coat, a number of round elementary cor- 
puscles, which are believed by Dr. Farre 2 to be the elementary form 
of the muscular fibres, and which he has traced in various intermediate 
states of development. Dr. John Williams 3 believes that a great part 



Muscular fibres <>!' unlmpregnated uterus. 

a. Fibres united by connective tissue, b. 
Separate fibres and elementary corpuscles. 
(After Farue.) 



Fig. 23, 




Developed muscular fibres from the gravid uterus. (After Wagner.) 

of the muscular tissue of the uterus, rather more indeed than three- 
fourths of its thickness, is an integral part of the mucous membrane, 
analogous to the mnscularis mucosa? of the mucous membrane of the 
alimentary canal. This he describes as being separated from the rest 
of the muscular tissue by a layer of rather loose connective tissue. 
containing numerous vessels. In early foetal life, and in the uteri of 
some of the lower animals, this appearance is very distinct ; in the 
adult female uterus, however, it can be readily made out. 

On examining the uterine tissue in an unimpregnated condition, no 
definite arrangement of its muscular fibres can be made out, and the 
whole seemed blended in inextricable confusion. By observation of 



1 Comparative Histology, vol. iii. ; Syd. Soc. Trans., p. 477. 

2 The Uterus and its Appendages, p. 632. 

3 "On the Structure of the Mucous Membrane of the Uterus," Obstet. Journ., 1875-6, vol. iii. p. 
490. 



62 ORGANS CONCERNED IN PARTURITION. 

their relations when hypertrophied during pregnancy, Helie 1 has 
shown that they may, speaking roughly, be divided into three layers : 
an external ; a middle, chiefly longitudinal ; and an internal, chiefly 
circular. Into the details of their distribution, as described by him, 
it is needless to enter at length. Briefly, however, he describes the 
external layer as arising posteriorly at the junction of the body and 
cervix, and spreading upward and over the fundus. From this are 
derived the muscular fibres found in the broad and round ligaments, 
and more particularly described by Rouget. The middle layer is 
made up of strong fasciculi, Avhich run upward, but decussate and 
unite with each other in a remarkable manner, so that those which 
are at first superficial become most deeply seated, and vice versa. The 
muscular fasciculi which form this coat curve in a circular manner 
round the large veins, so as to form a species of muscular canal 




From the body. From orifice of Fallopian tube. 
Lining membrane of uterus, showing network of capillaries and orifices of uterine glands. 

(After Farre.) 

through which they run. This arrangement is of peculiar importance, 
as it affords a satisfactory explanation of the mechanism by which 
hemorrhage after delivery is prevented. The internal layer is mainly 
composed of circular rings of muscular fibres, beginning around the 
openings of the Fallopian tubes, and forming wider and wider circles 
which eventually touch and interlace with each other. They surround 
the internal os, to which they form a kind of sphincter. In addition 
to these circular fibres on the internal uterine surface both anteriorly 
and posteriorly, there is a well-marked triangular layer of longitudinal 
fibres, the base being above and the apex below, which sends muscular 
fasciculi into the mucous membrane. 

The anatomy of the lining membrane of the uterus has been the 
subject of considerable discussion. Its existence has been denied by 
many authorities, most recently by Snow Beck, 2 who maintains that it 
is in no sense a mucous membrane, but only a softened portion of true 
uterine tissue. It is, however, pretty generally admitted by the best 
authorities that it is essentially a mucous membrane, differing from 
others only in being more closely adherent to the subjacent struc- 
tures, in consequence of not possessing any definite connective-tissue 
framework. 

It is a pale pink membrane of considerable thickness, most marked 

1 Recherches sur la Disposition des Fibres musculaires de l'Uterus. Paris, 1869. 

2 Obstet. Trans., 1872, vol. xiii. p. 294. 



THE FEMALE GENERATIVE ORGANS. 



f>3 



at the centre of the body, where it (onus from one-eighth to one-fourth 



At the internal 08 uteri 



Fk.. 2£ 



of the thickness of the whole uterine walls 
it terminates by a distinct border, which 
separates it from the mucous membrane 
lining the cervical cavity. 

On the surface of the mucous membrane 
may be observed a multitude of little open- 
ings, about one-thirtieth of a line in width 
(Fig. 24). These are the orifices of the 
utricular glands, which are found in im- 
mense numbers all over the cavity of the 
uterus, and very closely agglomerated to- 
gether. They are little cul-de-sacs, nar- 
rower at their mouths than in their length, 
the blind extremities of which are found in 
the subjacent tissues (Fig. 26). Williams 
describes them as running obliquely toward 
the surface at the lower third of the cavity, 
perpendicularly at its middle, while toward 
the fundus they are at first perpendicular, 
and then oblique in their course (Fig. 25). 
By others they are described as being often 
twisted and corkscrew-like. One or more 
may unite to form a common orifice, several 
of which may open together in little pits or 
depressions on the surface of the mucous 
membrane. These glands are composed of 
structureless membrane lined with epithe- 
lium, the precise character of which is 
doubtful. By some it is described as co- 
lumnar, by others as tessellated, and by some 
again as ciliated. The most generally re- 
ceived opinion is that it is columnar, but not 
ciliated; therein differing from the epithe- 
lium covering the surface of the membrane, which is undoubtedly 
ciliated, the movements of the cilia being from within outward. 
Williams, however, has observed cilia in active movement on the 
columnar epithelium lining the glands, and also states that at the 
deep-seated extremities of the glands, which penetrate between the 
muscular fibres for some distance, the columnar epithelium is replaced 
by rounded cells. The capillaries of the mucous membrane run down 
between the tubes, forming a lacework on their surfaces, and around 
their orifices. No true papillae exist in the membrane lining the 
uterine cavity. The mucous membrane of the uterus is peculiar in 
being always in a state of change and alteration, being thrown off at 
each menstrual period in the form of debris, in consequence of fatty 
degeneration of its structures, and re-formed afresh by proliferation of 
the cells of the muscular and connective tissues, probably from below 
upward, the new T membrane commencing at the internal os. Hence 
its appearance and structure vary considerably according to the time at 




The course of the glands in the 
fully developed mucous mem- 
brane of the uterus, viz., just 
before the onset of a menstrual 
period. (After Williams.) 



64 



ORGANS CONCERNED IN PARTURITION. 



which it is examined. The subject, however, will be more particularly 
studied in connection with menstruation. 

The mucous membrane of the cervix is much thicker and more 
transparent than that of the body of the uterus, from which it also 
differs in certain structural peculiarities. The general arrangements 
of its folds and surface have already been described. The lower half 
of the membrane lining the cavity of the cervix, and the whole of 
that covering its external or vaginal portion, are closely set with a 
large number of minute filiform, or clavate papillae (Fig. 27). Their 



Fig. 26. 




Vertical section through the mucous membrane of the human uterus, e. Columnar epithelium ; 
the cilia are not represented, g g. Utricular glands, ct ct. Interglandular connective tissue, v v. 
Bloodvessels, m m. Muscularis mucosse. (After Turner.) 



structure is similar to that of the mucous membrane itself, of which 
they seem to be merely elevations. They each contain a vascular loop 
(Fig. 28), and they are believed by Kilian and Farre to be mainly 
concerned in giving sensibility to this part of the generative tract. 
All over the interior of the cervix, both on the ridges of the mucous 
membrane and between their folds, are a very large number of mucous 
follicles consisting of a structureless membrane lined with cylindrical 
epithelium, and intimately united Avith connective tissue. They cease 
at the external orifice of the cervix, and they secrete the thick, tena- 
cious, and alkaline mucus which is generally found filling the cervical 
cavity. The transparent follicles, known as the ouula Xabothii, 
which are sometimes found in considerable numbers in the cavitv of 
the cervix, consist of mucous follicles the mouths of which have 



THE FEMALE GENERATIVE ORGANS 



65 



Fig. 27. 












f^ 







Villi of os uteri stripped of epithelium. (After Tyler Smith and Hassall.) 



Fig. 28. 






^'-^ 









6 










^v^yw^p 






j 51' 



311 




Villi of uterus, covered with pavement epithelium and containing looped vessels. (After 
Tyler Smith and Hassall.) 



66 ORGANS CONCERNED IN PARTURITION. 

become obstructed, and their canals distended by mucous secretion. The 
lower third of the cervical canal, as well as the exterior of the cervix, 
is covered with pavement epithelium ; while on its upper portion is 
found a columnar and ciliated epithelium similar to that lining the 
uterine cavity. 

Bandl 1 describes the cervical mucous membrane as extending much 
higher in the virgin than in women who have borne children, being 
traceable in the former nearly to the middle of the body of the uterus. 
During the first pregnancy he believes that the upper portion of the 
cervix is taken up into the body of the uterus, its mucous membrane 
never regaining the arrangement peculiar to that of the cervical canal. 

The arteries of the uterus are derived from the internal iliac and 
from the ovarian. They enter the uterus between the folds of the 
broad ligaments, and, penetrating its muscular coat, anastomose freely 
with each other and with the corresponding vessels of the opposite 
side. They are described by Williams 2 as entering the uterus on its 
sides and then running a somewhat superficial course, being separated 
from the peritoneum by a thin layer of muscular fibres. They are 
here placed in a distinct layer of connective tissue, and give oft 
branches which pass perpendicularly toward the uterine canal. Their 
walls are thick and well developed, and they are remarkable for their 
very tortuous course, forming spiral curves, especially in the upper 
part of the uterus. They end in minute capillaries which form the 
fine meshes surrounding the glands, and in the cervix give off the 
loops entering the papilla?. Beneath the uterine mucous membrane 
these capillaries form a plexus, terminating in veins without valves, 
which unite with each other to form the large veins traversing the 
substance of the uterus, known during j^regnancy as the uterine 
sinuses, the walls of which are closely adherent to the uterine tissues. 
These veins run a similar course to the arteries, and end in a venous 
plexus lying in the layer of connective tissue already mentioned, which 
Williams believes to be the true submucous tissue of the uterus, the 
thick layer of muscular tissue between it and the uterine cavity being 
really " museularis mucosa?." In consequence of this arrangement the 
circulation of the uterus can hardly be disturbed by mechanical causes. 
The veins, freely anastomosing with each other, pass from the uterus 
to the folds of the broad ligaments, where they unite to form, with the 
ovarian and vaginal veins, a large and well-developed venous network, 
known as the pampiniform plexus. 

The lymphatics of the uterus are large and well developed, and they 
have recently, and with much probability, been supposed to play an 
important part in the production of certain puerperal diseases. A 
more minute knowledge than we at present possess of their course and 
distribution will probably throw much light on their influence in this 
respect. According to the researches of Leopold, 3 who has studied 
their minute anatomy carefully, they originate in lymph spaces between 
the fine bundles of connective tissue forming the basis of the mucous 

i Arch. f. Gvnak., 1879, Bd. xiv., S. 237. 

2 Trans. Obst. Society, 1885, vol. xxvii. p. 112. 

s Arch. f. Gvnak., 1S73, Bd. vi., Heft 1, S. 1. 



THE FEMALE GENERATIVE ORGANS. 



• 17 



lining of the uterus. Bere they are in intimate contad with the 
utricular glands and the ultimate ramifications of the uterine blood- 
vessels. As they pass into the muscular tissue they become gradually 
narrowed into lymph-vessels and spaces, which have a very compli- 
cated arrangement, and which eventually unite together in the external 
muscular layer, especially on the sides of the uterus, to form large 
canals which probably have valves. Immediately under the perito- 
neum these lymph-vessels form a large and characteristic network 
covering the anterior and posterior surfaces of the uterus, and present, 
in various parts of their course, large ampullae. They then spread 
over the Fallopian tubes. The lymphatics of the body of the uterus 
unite with the lumbar glands, those of the cervix with the pelvic 
glands. 

The distribution and arrangement of the nerves of the uterus have 
been the subject of much controversy. They are derived mainly from 
the ovarian and hypogastric plexuses, inosculating freely with each other 
between the folds of the broad ligament, from which they enter the 
muscular tissue of the uterus, generally, but not invariably, following 
the course of the arteries. They are chiefly derived from the sympa- 
thetic ; but, as the hypogastric plexus is connected with the sacra] 
nerves, it is probable that some fibres from the cerebrospinal system 
are distributed to the cervix. It is now generally admitted that 
nervous filaments are distributed to the cervix, even as far as the 
external os, although their existence in this situation has been denied 
by Jobert and other writers. The ultimate distribution of the nerves 
is not yet made out. Polle describes a nerve filament as entering the 
papilla? of the cervical mucous membrane along with the capillary 
loop, and Frankenhauser says the nerve fibres surround the muscles of 
the uterus in the form of plexuses, and terminate in the nuclei of the 
muscle cells. 

Anomalies of the Uterus. — Various abnormal conditions of the 
uterus and vagina are occasionally met with, which it is necessary to 



Fig. 29, 




Bifid uterus. | After Farre.) 



mention, as they may have an important practical bearing on parturition. 

The most frequent of these is the existence of a double, or partially 



68 ORGANS CONCERNED IN PARTURITION. 

double uterus (Fig. 29), similar to that found normally in many of 
the lower animals. This abnormality is explained by the development 
of the organ during foetal life. The uterus is formed out of struc- 
tures existing only in early foetal life, known as the Wolffian bodies. 
These consist of a number of tubes, situated on either side of the 
vertebral column, and opening externally into an excretory duct. 
Along their external border a hollow canal is formed, termed the canal 
of Miiller, which, like the excretory ducts, proceeds to the common 
cloaca of the digestive and urinary organs which then exists. The 
canal of Miiller unites with its fellow of the opposite side to form the 
uterus and Fallopian tubes in the female, and subsequently the central 
partition at their point of junction disappears. If, however, the pro- 
gress of development be in any way checked, the central partition may 
remain. Then we have produced either a complete double uterus or 
the uterus bicornis, which is bifid at its upper extremity only ; or a 
double vagina, each leading to a separate uterus. 

If pregnancy occur in any of these anomalous uteri, and many such 
cases are recorded, serious troubles may follow. It may happen that 
one horn of the double uterus is not sufficiently large to admit of preg- 
nancy going on to term, and rupture may occur. It is supposed that 
some cases, presumed to be tubal gestation, are really thus explicable. 
Impregnation may also occur in the two cornua at different times, 
leading to super foetation. It is, however, quite possible that impreg- 
nation may occur in one horn of a bifid uterus, and labor be com- 
pleted without anything unusual being observed. A remarkable case 
of this sort has been recorded by Dr. Ross, of Brighton, 1 in which a 
patient miscarried of twins on July 16, 1870, and on October 31st, 
fifteen weeks later, she was delivered of a healthy child. Careful 
examination showed the existence of a complete double uterus, each 
side of which had been impregnated. Curiously enough, this patient had 
formerly given birth to six living children at term, nothing remark- 
able having been observed in her labors. It can only rarely happen 
that, under such circumstances, so favorable a result will follow, and 
more or less difficulty and danger may generally be expected. Occasion- 
ally the vagina only is double, the uterus being single. Dr. Matthews 
Duncan has recorded some cases of this kind, 2 in which the vaginal sep- 
tum formed an obstacle to the birth of the child, and required division. 

[Double uteri are of several distinct types, the extremes of which are 
the " partitioned uterus," where the organ is single without, and double 
within, and the " completely bifid uterus," where there is a double 
vagina and cervix with a Y-shaped or double-barrelled body. The 
former can only be diagnosticated from within and is rarely discovered 
until after the second stage of a labor has been completed. In a case 
reported by Dr. B. F. Baer, of Philadelphia, the patient bore twins, 
one foetus from each compartment, the birth of which was followed by 
two single placentae at intervals of a quarter of an hour. Where there 
is only one foetus the uterus develops mainly on one side, and the 
unoccupied one lies much lower than the fundus of the other. Dr. 

1 Lancet, 1871, vol. ii. p. 188. 2 Researches in Obstetrics, p. 443. 



THE FEMALE GENERATIVE ORGANS 



69 



Drysdale, of this city, discovered one such case by the touch after 
labor, and no doubt a careful scrutiny would find thai they arc less 
rare than might be presumed. 

Where one side of a bifid uterus is Impregnated, the unoccupied 
one rotates into the hollow of the sacrum, and the other develops 
under the abdominal wall, The sound will readily enter the empty 
half of the organ in the median line, and may lead to an error in diag- 
nosis, the pregnancy being regarded as extra-uterine, Very skilful 
obstetricians have been deceived in this wav. 







Uterus septus uniformis. a. Vagina, b. Siugle os uteri, c. Partition of uterus, thick above and 
thin below dd. Right and left uterine cavities, ee. Two ridges in the posterior wall of the 
cervix. (From Kussmaul, after Gravel.) 



Pregnancy in a uterus unicornus is apt to terminate fatally by rup- 
ture, but exceptional eases may occur and the foetus be delivered at 
term. In one ease seen by the writer the development of the abnormal 
uterus gave rise to much pain and distress for several months, and an 
extra-uterine pregnancy was regarded as almost certain by the family 
physician. The child was a female of four pounds, and died in three 
days from an undeveloped duodenum and an imperforate rectum : the 
eornu was on the right side. — Ed.] 

Ligaments of the Uterus. — The various folds of peritoneum which 
invest the uterus serve to maintain it in position, and they are described 
as its ligaments. They are the broad, the vesico-uterine, and sacro- 
uterine ligaments ; the round ligaments are not peritoneal folds like 
the other-. 

The broad ligaments extend from either side of the uterus, where 
their lamime are separated from each other, transversely across to the 



70 ORGANS CONCERNED IN PARTURITION. 

pelvic wall, and thus divide the cavity of the pelvis into two parts ; 
the anterior containing the bladder, the posterior the rectum. Their 
upper borders are divided into three subsidiary folds, the anterior of 
which contains the round ligament, the middle the Fallopian tube, 
and the posterior the ovary. The arrangement has received the name 
of the ala vespertilionis, from its fancied resemblance to a bat's wing. 
Between the folds of the broad ligaments are found the uterine vessels 
and nerves, and a certain amount of loose cellular tissue continuous 
with the pelvic fasciae. Here is situated that peculiar structure called 
the organ of Rosenmiiller, or the parovarium (Fig. 31), which is the 
remains of the Wolffian body, and corresponds to the epididymis in the 
male. This may best be seen in young subjects, by holding up the 
broad ligaments and looking through them by transmitted light ; but 
it exists at all ages. It consists of several tubes (eight or ten according 

Fig. 31. 




Adult paro\ arium, ovary, and Fallopian tube. (After Kobelt. 

to Farre, eighteen or twenty accoramg L o Bankes 1 ), which are tortuous 
in their course. They are arranged in a pyramidal form, the base of 
the pyramid being toward the Fallopian tube, its apex being lost on 
the surface of the ovary. They are formed of fibrous tissue, and lined 
with pavement epithelium. They have no excretory duct or commu- 
nication with either the uterus or ovary, and their function, if they 
have any, is unknown 

A number of muscular fibres are also found in this situation, lying 
between the meshes of the connective tissue. They have been particu- 
larly studied by Rouget, who describes them as interlacing with each 
other, and forming an open network, continuous with the muscular 
tissues of the uterus (Fig. 32). They are divisible into two layers, the 
anterior of which is continuous with the muscular fibres of the anterior 
surface of the uterus, and goes to form part of the round ligament ; 
the posterior arises from the posterior wall of the uterus, and proceeds 
transversely outward, to become attached to the sacro-iliac synchon- 
drosis. A continuous muscular envelope is thus formed, which sur- 

1 Bankes : On the Wolffian Bodies. 



THE FEMALE GENERATIVE ORGANS 



71 



rounds the whole of the uterus, Fallopian tubes, and ovaries. Its 
function is not yet thoroughly established. It is supposed to have the 
effect of retracting the stretched folds of peritoneum after delivery, and 
more especially of bringing the entire generative organa into harmoni- 
ous action during menstruation and the sexual orgasm j in this way 
explaining, as we shall subsequently see, the mechanism by which the 
fimbriated extremity of the Fallopian tube is said to grasp the ovary 
prior to the rupture of a Graafian follicle. 



Fig. 82. 



<s 




^m 



W?M 




M 



\; 




j&£^ 1Mnt , i 



Posterior view of muscular and vascular arrangements. Vessels.— 1, 2, 3. Vaginal, cervical, and 
uterine plexuses. 4. Arteries of body of uterus. 5. Arteries supplying ovary. Muscular fasci~ 
culi.—6, 7. Fibres attached to vagina, symphysis pubis, and sacro-iliac joint. 8. Muscular fasiculi 
from uterus and broad ligaments. 9, 10, 11, 12. Fasiculi attached to ovary and Fallopian tubes. 
(After Rouget.) 

The round ligaments are essentially muscular in structure. They 
extend from the upper border of the uterus, with the fibres of which 
their muscular fibres are continuous, transversely, and then obliquely 
downward, until they reach the inguinal rings, where they blend with 
the cellular tissue. In the first part of their course the muscular 
fibres are solely of the unstriped variety, but soon they receive striped 
fibres from the transversalis muscles, and the columns of the inguinal 
ring, which surround and cover the unstriped muscular tissue. In 
addition to these structures they contain elastic- and connective tissue, 
and arterial, venous, and nervous branches; the former from the 
iliac or cremasteric arteries, the latter from the gcnito-crural nerve. 



72 ORGANS CONCERNED IN PARTURITION. 

According to Ranney, 1 the principal function of these ligaments is to 
draw the uterus toward the symphysis pubis during sexual intercourse, 
and thus to favor the ascent of the semen. 

The vesico-uterine ligaments are two folds of peritoneum pass- 
ing in front from the lower part of the body of the uterus to the fundus 
of the bladder. 

The utero-sacral ligaments consist of folds of peritoneum of a 
crescentic form, with their concavities looking inward; they start from 
the lower part of the posterior surface of the uterus, and curve back- 
ward to be attached to the third and fourth sacral vertebrae. Within 
their folds exist bundles of muscular fibres, continuous with those of 
the uterus, as well as connective tissue, vessels, and nerves. The 
experiments of Savage, as well as of other anatomists, show that these 
ligaments have an important influence in preventing downward dis- 
placement of the womb. 

During pregnancy all these ligaments become greatly stretched and 
unfolded, rising out of the pelvic cavity and accommodating themselves 
to the increased size of the gravid uterus ; and they again contract to 
their natural size, possibly through the agency of the muscular fibres 
contained within them, after delivery has taken place. 

The Fallopian tubes, the homologues of the vasa deferentia in the 
male, are structures of great physiological interest. They serve the 
double purpose of conveying the semen to the ovary, and of carrying 
the ovule to the uterus. From the latter function they may be looked 
on as the excretory ducts of the ovaries ; but, unlike other excretory 
ducts, they are movable, so that they may apply themselves to the 
part of the ovaries from which the ovule is to come ; and so great is 
their mobility that there is reason to believe that a Fallopian tube 
may even grasp the ovary of the opposite side. Each tube proceeds 
from the upper angle of the uterus at first transversely outward, and 
then downward, backward, and inward, so as to reach the neighbor- 
hood of the ovary. In the first part of its course it is straight, after- 
ward it becomes flexuous and twisted on itself. It is contained in the 
upper part of the broad ligament, where it may be felt as a hard cord. 
It commences at the uterus by a narrow opening, admitting only the 
passage of a bristle, known as ostium uterinum. As it passes through 
the muscular walls of the uterus, the tube takes a somewhat curved 
course, and opens into the uterine cavity by a dilated aperture. From 
its uterine attachment the tube expands gradually until it terminates 
in its trumpet-shaped extremity ; just before its distal end, however, 
it again contracts slightly. The ovarian end of the tube is surrounded 
by a number of remarkable fringe-like processes. These consist of 
longitudinal membranous fimbriae, surrounding the aperture of the 
tube, like the tentacles of a polyp, varying considerably in number 
and size, and having their edges cut and subdivided. On their inner 
surface are found both transverse and longitudinal folds of mucous 
membrane, continuous with those lining the tube itself (Fig. 33). One 
of these fimbriae is always larger and more developed than the rest, 

1 Amer. Journ. Obstet., 1883, vol. xvi. p. 225. 



THE FEMALE GENERATIVE ORGANS. 



73 



and is indirectly united to the surface of the ovary by a fold of peri- 
toneum proceeding from its external surface. Its under surface is 
grooved so as to form a channel, open below. The function of this 
fringe-like structure, as has been supposed, is to grasp the ovary during 
the menstrual nisus; and the fimbria which is attached to the ovary 
would seem to guide the tentacles to the ovary which they are intended 
to seize. It has never, however, been demonstrated that this grasping 
of the ovary actually occurs. One or more supplementary series of 
fimbriae sometimes exist, which have an aperture of* communication 
with the canal of the Fallopian tube, beyond its ovarian extremity. 
His ha- recently shown that the fimbriated extremity of the tube, after 
running over the upper part of the ovary, turns down along its free 
'border ; so that its aperture lies helow it, ready to receive the ovule 
when expelled from the Graafian follicle. 1 



Fig. 33. 




Fallopian tube laid open, a, b. Uterine portion of tube, 
brane. e. Tubo-ovarian ligaments and fringes. /. Ovary. 
Richard.) 



c. d. Plic?e of mucous mem- 
g. Round ligaments. (After 



The tubes themselves consist of peritoneal, muscular, and mucous 
coats. The peritoneum surrounds the tube for three-fourths of its 
calibre, and comes into contact with the mucous lining at its fimbriated 
extremity, the only instance in the body where such a junction occurs. 
The muscular coat is principally composed of circular fibres, with a 
few longitudinal fibres interspersed. Its muscular character has been 
doubted, but Farre had no difficulty in demonstrating the existence of 
muscular fibres, both in the human female and many of the lower 
animals. According to Robin, the muscular tissue of the Fallopian 
tubes is entirely distinct from that of the uterus, from which he 
describes it as being separated by a distinct cellular septum. The 
mucous lining is thrown into a number of remarkable longitudinal 
folds, each of which contains a dense and vascular fibrous septum, with 



1 His : Archiv fur Anat. und Phys., 18S1. 



74 ORGANS CONCERNED IN PARTURITION. 

small muscular fibres, and is covered with columnar and ciliated epi- 
thelium. The apposition of these produces a series of minute capillary 
tubes, along which the ovules are propelled, the action of the cilia, 
which is toward the uterus, apparently favoring their progress. 

The ovaries are the bodies in which the ovules are formed, and 
from which they are expelled, and the changes going on in them in 
connection with the process of ovulation, during the whole period 
between the establishment of puberty and the cessation of menstruation, 
have an enormous influence on the female economy. Normally, the 
ovaries are two in number; in some exceptional cases a supplementary 
ovary has been discovered ; or they may be entirely absent. They 
are placed in the posterior folds of the broad ligaments, usually below 
the brim of the pelvis, behind the Fallopian tubes, the left in front of 
the rectum, the right in front of some coils of the small intestine. 
Their situation varies, however, very much under different circum- 
stances, so that they can scarcely be said to have a fixed and normal 
position ; most probably, however, as has been recently shown by His, 1 
they are normally placed close below the brim of the pelvis, with their 
long diameters almost vertical, and immediately above the aperture of 
the distal extremity of the Fallopian tubes. In pregnancy they rise 
into the abdominal cavity with the enlarging uterus ; and in certain 
conditions they are dislocated downward into Douglas's space, where 
they may be felt through the vagina as rounded and very tender 
bodies. 

The folds of the broad ligament form for them a kind of loose 
mesentery. Each of them is united to the upper angle of the uterus 
by a special ligament called the utero-ovarian. This is a rounded 
band of organic muscular fibres, about an inch in length, continuous 
with the superficial muscular fibres of the posterior Avail of the uterus, 
and attached to the inner extremity of the ovary. It is surrounded 
by peritoneum, and through it the muscular fibres, which form an 
important integral part in the structure of the ovaries, are conveyed to 
them. The ovary is also attached to the fimbriated extremity of the 
Fallopian tube in the manner already described. 

The ovary is of an irregular oval shape (Fig. 34), the upper border 
being convex, the lower — through which the vessels and nerves enter 
— being straight. The anterior surface, like that of the uterus, is less 
oonvex than the posterior. The outer extremity is more rounded and 
bulbous than the inner, which is somewhat pointed and eventually lost 
in its proper ligament. By these peculiarities it is possible to dis- 
tinguish the left from the right ovary, after they have been removed 
from the body. The ovary varies much in size under different cir- 
cumstances. On an average, in adult life it measures from one to two 
inches in length, three-quarters of an inch in width, and about half 
an inch in thickness. It increases greatly in size during each men- 
strual period — a fact which has been demonstrated in certain cases of 
ovarian hernia, in which the protruded ovary has been seen to swell 
as menstruation commenced ; also during pregnancy, when it is said 

i Op. cit. 



THE FEMALE GENERATIVE ORGANS. 



75 



to be double its usual size. Alter the change of life ii atrophies, and 
becomes rough and wrinked on its surface. Before puberty, the sur- 
face of the ovary is smooth and polished, and of a whitish color. 
Alter menstruation commences, its surface becomes Bcarred by the 
rupture of the Graafian follicles (Fig. 3 1, a a a), each of which leaves a 
little linear or striated cicatrix, of a brownish color ; and the older the 
patient the greater are the number of these cicatrices. 




-A 



a a Ovary enlarged under menstrual nisus. b. Ripe follicle projecting on its surface. 
aaa Traces of previously ruptured follicles, 



The structure of the ovary has been made the subject of many 
important observations. It has an external covering of epithelium, 
originally continuous with the peritoneum, called by some the germ- 
epithelium, in consequence of the ovules being formed from it in early 
foetal life. In the adult it is separated from the peritoneum at the 
base of the organ by a circular white line, and it consists of columnar 
epithelium, differing only from the epithelium lining the Fallopian 
tubes, with which it is sometimes continuous through the attached 
fimbria uniting the tube and the ovary, in being destitute of cilia. 
Immediately beneath this covering is the dense coat known as the 
tunica albuginea, on account of its whitish color. It consists of short 
connective-tissue fibres, arranged in lamina?, among which are inter- 
spersed fusiform muscular fibres. At the point where the vessels and 
nerves enter the ovary this membrane is raised into a ridge, which is 
continuous with the utero-ovarian ligament, and is called the hilum. 
The tunica albuginea is so intimately blended with the stroma of the 
ovary as to be inseparable on dissection; it does not, therefore, exist 
as a distinct lamina, but is merely the external part of the proper 
structure of the ovary, in which more dense connective tissue is devel- 
oped than elsewhere. 

On making a longitudinal section of the ovary (Fig. 35), it will be 
seen to be composed of two parts, the more internal of which is of a 
reddish color from the number of vessels that ramify in it, and is 
called the medullary or vascular zone ; while the external, of a whitish 



76 



OEGANS CONCERNED IN PARTURITION. 



Fig. 35. 



tint, receives the name of the cortical or parenchymatous substance. 
The former consists of loose connective tissue interspersed with elastic, 

and a considerable number of muscular 
fibres. According to Rouget l and His 2 the 
muscular structure forms the greater part of 
the ovarian stroma. The latter describes it 
as consisting essentially of interwoven mus- 
cular fibres, which he terms the " fusiform 
tissue," and which he believes to be con- 
tinuous with the muscular layers of the 
ovarian vessels. The former believes that 
the muscular fasciculi accompany the vessels 
in the form of sheaths, as in erectile tissues. 
Both attribute to the muscular tissues an 
important influence in the expulsion of the 
ovules, and in the rupture of the Graafian 
follicles. Waldeyer and other writers, how- 
ever, do not consider it to be so extensively developed as Rouget and His 
believe. The cortical substance is the more important, as that in which 
the Graafian follicles and ovules are formed. It consists of interlaced 
fibres of connective tissue, containing a large number of nuclei. The 




Longitudinal section of adult 
ovary. (After Farre.) 



Fig. 36. 




Section through the cortical part of the ovary, e. Surface epithelium, s s. Ovarian stroma. 
11. Large-sized Graafian follicles.. 2 2. Middle-sized; and 3 3. Small-sized Graafian follicles. 
o. Ovule within Graafian follicle, v v. Bloodvessels in the stroma, g. Cells of the membrana gran- 
ulosa. (After Turner.) 

muscular fibres of the medullary substance do not seem to penetrate 
into it in the human female. In it are found the Graafian follicles, 
which exist in enormous numbers from the earliest periods of life, and 
in all stages of development (Fig. 36). 



1 Journal de Physiol, i. p. 737. 

2 Schultze's Arch. f. mikroscop. Anat. 



1865. 



THE FEMALE 6EXEKATIVK ORGANS. 77 

The Graafian Follicles.— According to the researches of Pfluger 
Waldeyer, and other German writers, the Graafian follicles are formed 
in early foetal life by cylindrical Inflections of the epithelial covering 
of the ovary, which dip into the substance of the gland. These tubular 
filaments anastomose with each other, and in Oiem are formed the 
ovules, which are originally the epithejial cells lining the tubes. Por- 
tions become shut off from the resl of the filaments, and form the 
Graafian follicles. The ovules, on this view, are highly developed 
epithelial cells, originally derived from the surface of the ovary, and 
not developed in its stroma. These tubular filaments disappear shortly 
after birth, but they have recently been detected by Slavyansky 1 in 
the ovaries of a woman thirty years of age. These observations have 
been modified by Dr. Foulis. 2 He recognizes the origin of the ovules 
from the germ-epithelium covering the surface of the ovary, which is 
itself derived from the Wolffian body. He believes all the ovules to 



fttiflSlfe 



?ft 




Vertical section through the ovary of the human foetus, gg. Germ-epithelium, with o o. Develop- 
ing ovules in it. s s. Ovarian stroma containing c c c. Fusiform connective-tissue corpuscles. 
v v. Capillary bloodvessels. In the centre of the figure an involution of the germ-epithelium is 
shown ; an<l at the left lower side a primordial ovule, with the connective-tissue corpuscles 
ranging themselves round it. (After Foulis.) 

be formed from the germ-epithelium corpuscles. Some of these, which 
are differentiated from the rest by their greater size, rounded shape, 
and large nuclei, become imbedded in the stroma of the ovary by the 
outgrowth of processes of vascular connective tissue, fresh germ- 
epithelial corpuscles being constantly produced on the surface of the 
organ up to the age of two and a half years, to take the place of those 
already imbedded in its stroma. He believes the Graafian follicles to 
be formed bv the growth of delicate processes of connective tissue 
between and around the ovules, but not from tubular inflections of the 
epithelium covering the gland, as described by Waldeyer (Fig. 37). 
This view is supported by the researches of Balfour, 3 who arrives at 
the conclusion that the whole egg-containing part of the ovary is really 

1 Annales de Gynec. Feb. 1871. 

2 Proceedings o*f the Roval Soc.of Edinb., April, 1875. and Journ. of Anat. and Phys.,vol. xiii.1879. 

3 F. M. Balfour: "Structure and Development of Vertebrate Ovary." Quarterly Journal of Micro- 
scopical Science, vol. xviii., 1878. 



78 



ORGANS CONCERNED IN PARTURITION 



the thickened germinal epithelium, broken up into* a kind of mesh- 
work by growths of vascular stroma. According to this theory, 
Pfliiger's tubular filaments are merely trabecule? of germinal epithe- 
lium, modified cells of which become developed into ovules. 

The greater proportion of the Graafian follicles are only visible with 
the high powers of the microscope, but those which are approaching 
maturity are distinctly to be seen by the naked eye. The quantity of 
these follicles is immense. Foulis estimates that at birth each human 
ovary contains not less than 30,000. No fresh follicles appear to be 
formed after birth, and as development goes on, some only grow, and, 
by pressure on the others, destroy them. Of those that grow, of course 
only a few ever reach maturity ; they are scattered through the sub- 
stance of the ovary, some developing in the stroma, others on the sur- 
face of the organ, where they eventually burst, and are discharged into 
the Fallopian tube. 

A ripe Graafian follicle has an external investing membrane (Fig, 
38), which is generally described as consisting of two distinct layers : 

the external, or tunica fibrosa, 
FlG - 38 - highly vascular, and formed of 

connective tissue ; the internal, 
or tunica propria, composed of 
young connective tissue, con- 
taining a large number of fusi- 
form or stellate cells, and form- 
ing a basement membrane to the 
epithelial layer which lies inter- 
nal to it. These layers, however, 
appear to be essentially formed 
of condensed ovarian stroma. 
Within this capsule is the epithe- 
lial lining called the membrana 
granulosa, consisting of colum- 
nar epithelial cells, which, 
according to Foulis, are origi- 
nally formed from the nuclei of 
the fibro-nuclear tissue of the 
stroma of the ovary, but which, according to Waldeyer and Balfour, 
are formed from the germinal epithelium itself. At one part of the 
circumference of the ovisac is situated the ovule, around which 
the epithelial cells are congregated in greater quantity, constituting 
the projection known as the discus proligerus. The remainder of the 
cavity of the follicle is filled with a small quantity of transparent 
fluid, the liquor folliculi, traversed by three or four minute bands, the 
retinacula of Barry, which are attached to the opposite walls of the 
follicular cavity, and apparently serve the purpose of suspending 
the ovule and maintaining it in a proper position. In many young 
follicles this cavity does not at first exist, the follicle being entirely 
filled by the ovule. According to Waldeyer, the liquor folliculi is 
formed by the disintegration of the epithelial cells, the fluid thus 
produced collecting, and distending the interior of the follicle. 




Diagrammatic section of Graafian follicle. 1. 
Ovum. 2. Membrana granulosa. 3. External 
membrane of Graafian follicle, i. Its vessels. 5. 
Ovarian stroma. 6. Cavity of Graafian follicle. 
7. External covering of ovary. 



THE FEMALE GENERATIVE ORGANS. 



70 



The Ovule. — The ovule is attached to some part of the internal 
surface of the Graafian follicle. It is a rounded vesicle aboul , .', ,, 
of an inch in diameter, and is surrounded bv a layer of columnar cells, 

distinct from those of the discus proligerus, in which it lies. It is 
invested bv a transparent elastic membrane, the zona pellucida, or vitel- 
line membrane. In most of the lower animals the zona pellucida is 
perforated by numerous very minute pores, only visible under the 
highest powers of the microscope ; in others there is a distinct aperture 
of a larger size, the micropyle, allowing the passage of the spermatozoa 
into the interior of the ovule. It is possible that similar apertures ma} 
exist in the human ovule, but they have not been demonstrated. 
Within the zona pellucida some embryologists describe a second fine 
membrane, the existence of which has been denied by Bischoff. The 
cavity of the ovule is filled with a viscid yellow fluid, the yelk, con- 
taining numerous granules. It entirely fills the cavity, to the walls of 
which it is non-adherent. It consists of primitive cell matter, called 
the protoplasm of the yelk, from which the embryo is developed, and 
of the granules, called the deutoplasm, which furnish the nutritive 
material for cell growth. In the centre of the yelk in young, and at 
some portion of the periphery in mature ovules, it situated the germinal 
vesicle, which is a clear circular vesicle, refracting light strongly, and 
about gV of a line in diameter. It contains a few granules, and a 
nucleolus, or germinal spot, which is sometimes double. 



Fig. 39. 




Bulb of ovary, u. Uterus, o. Ovary and utero-ovarian ligament, t. Fallopian tube. 1. Utero- 
ovarian vein. 2. Pampiniform ovarian plexus. 3. Commencement of spermatic vein. 



From within outward, therefore, we find — 



1. The germinal spot ; round this 

2. The germinal vesicle contained in 

3. The yelk, which is surrounded by the 

4. Zona pellucida, with its layers of colu 



pellucida. 
These constitute the ovule. 



umnar epithelial cells. 



The ovule is contained in- 
The Graafian follicle, and 
called the — 



in that part of its epithelial lining 



80 



ORGANS CONCERNED IN PARTURITION, 



Fig. 40. 



JJiscus proligerus, the rest of the follicle being occupied by the liquor 
folliculi. Round these we have the epithelial lining or membrana gran- 
ulosa, and the external coat, consisting of the tunica propria and the 
tunica fibrosa. 

The vascular supply of the ovary is complex. The arteries enter at 
the hilurn, penetrating the stroma in a spiral curve, and are ultimately 
distributed in a rich capillary plexus to the follicles. The large veins 
unite freely with each other, and form a vascular and erectile plexus, 
continuous with that surrounding the uterus, called the bulb of the 
ovary (Fig. 39). Lymphatics and nerves exist, but their mode of 
termination is unknown. 

The Mammary Glands. — To complete the consideration of the 
generative organs of the female, we must study the mammary glands, 
which secrete the fluid destined to nourish the child. In the human 
subject they are two in number, and instead of being placed upon the 

abdomen, as in most animals, they are 
situated on either side of the sternum, 
over the pectorales majora muscles, and 
extend from the third to the sixth ribs. 
This position of the glands is obviously 
intended to suit the erect position of the 
female in suckling. They are convex 
anteriorly, and flattened posteriorly where 
they rest on the muscles. They vary 
greatly in size in different subjects, chiefly 
in proportion to the amount of adipose 
tissue they contain. In man, and in girls 
previous to puberty, they are rudimentary 
in structure; while in pregnant women 
they increase greatly in size, the true glan- 
dular structures becoming much hypertro- 
phied. Anomalies in shape and position 
are sometimes observed. Supplementary 
mammae, one or more in number, situated 
on the upper portion of the mammae are 
sometimes met with, identical in structure 
with the normally situated glands ; or, 
more commonly, an extra nipple is observed by the side of the normal 
one. In some races, especially the African, the mammae are so enor- 
mously developed that the mother is able to suckle her child over her 
shoulder. 

The skin covering the gland is soft and supple, and during preg- 
nancy often becomes covered with fine white lines, while large blue 
veins may be observed coursing over. Underneath it is a quantity of 
connective tissue, containing a considerable amount of fat, which ex- 
tends between the true glandular structure. This is composed of from 
fifteen to twenty lobes, each of which is formed of a number of lobules. 
The lobules are produced by the aggregation of the terminal acini in 
which the milk is formed. The acini are minute cul-de-sacs opening 
into little ducts, which unite with each other until they form a large 




1. Galactophorous ducts. 2. Lobuli 
of the mammary gland. 



THE FEMALE GENERATIVE ORGANS. Si 

duct for each lobule; the ducts of each lobule unite with each other 

until they end in a still larger duct common to each of the lifter • 

twenty lobes into which the gland Is divided, and eventually open on 
the surface of the nipple. These terminal canals are known as the 
galactophorous ducts (Fig. 40). They become widely diluted as tin, 
approach the nipple, so as to form reservoirs in which milk is stored 
until it is required, hut when they actually cuter the nipple they again 
contract. Sometimes they give oil' lateral branches, but, according to 
Sappey, they do not anastomose with each other, as some anatomists 
have described. These excretory ducts are composed of connective 
tissue, with numerous elastic fibres on their external surface. Sappey 
and Kobin describe a layer of muscular fibres, chiefly developed near 
their terminal extremities. They are lined with columnar epithelium, 
continuous with that in the acini; and it is by the distention of its 
cells with fatty matter, and their subsequent bursting, that the milk is 
formed. 

The nipple is the conical projection at the summit of the mamma, 
and it varies in size in different women. Not unfrequently, from the 
continuous pressure to which it has been subjected by the dress, it is so 
depressed below the surface of the skin as to prevent lactation. It is 
generally larger in married than in single women, and increases in size 
during pregnancy. Its surface is covered with numerous papillae, 
giving it a rugous aspect, and at their bases the orifices of the lactifer- 
ous ducts open. Here are also the opening of numerous sebaceous 
follicles, which secrete an unctuous material supposed to protect and 
soften the integument during lactation. Beneath the skin are muscular 
fibres, mixed with connective and elastic tissues, vessels, nerves, and 
lymphatics. When the nipple is irritated it contracts and hardens, 
and by some this is attributed to its erectile properties. The vascu- 
larity, however, is not great, and it contains no true erectile tissue; the 
hardening is, therefore, due to muscular contraction. Surrounding the 
nipple is the areola, of a pink color in virgins, becoming dark from the 
development of pigment cells during pregnancy, and always remaining 
somewhat dark after childbearing. On its surface are a number of 
prominent tubercles, sixteen to twenty in number, which also become 
largely developed during gestation. They are supposed by some to 
secrete milk, and to open into the lactiferous tubes; most probably 
they are composed of sebaceous glands only. Beneath the areola is a 
circular band of muscular fibres, the object of which is to compress the 
lactiferous tubes which run through it, and thus to favor the expulsion 
of their contents. The mammae receive their blood from the internal 
mammary and intercostal arteries, and they are richly supplied with 
lymphatic vessels, which open into the axillary gland. The nerves are 
derived from the intercostal and thoracic branches of the brachial 
plexus. 

The secretion of milk in women who are nursing is accompanied by 
a peculiar sensation, as if milk wen; rushing into the breast, called the 
''draught, " which is excited by the efforts of the child to suck, and by 
various other causes. The sympathetic relations between the ma mime 

C 



82 ORGANS CONCERNED IN PARTURITION. 

and the uterus are very well marked, as is shown in the unimpregnated 
state by the fact of the frequent occurrence of sympathetic pains in the 
breast in connection with various uterine diseases; and, after delivery, 
by the well-known fact that suction produces reflex contraction of the 
uterus and even severe after-pains. 



CHAPTEE III. 

OVULATION AND MENSTEUATION. 

Functions of the Ovary. — The main function of the ovary is to 
supply the female generative element, and to expel it, when ready for 
impregnation, into the Fallopian tube, along which it passes into the 
uterus. This process takes place spontaneously in all viviparous ani- 
mals, and without the assistance of the male. In the lower animals 
this periodical discharge receives the name of the oestrum or rut, at 
which time only the female is capable of impregnation and admits the 
approach of the male. In the human female the periodical discharge 
of the ovule, in all probability, takes place in connection with menstru- 
ation, which may therefore be considered to be the analogue of the rut 
in animals. Between each menstrual period Graafian follicles undergo 
changes which prepare them for rupture and the discharge of their 
contained ovules. After rupture certain changes occur which have for 
their object the healing of the rent in the ovarian tissue through which 
the ovule has escaped, and the filling up of the cavity in which it was 
contained. This results in tlie formation of a peculiar body in the 
substance of the ovary, called the corpus luteum, which is essentially 
modified should pregnancy occur, and is of great interest and impor- 
tance. During the whole of the childbearing epoch the periodical 
maturation and rupture of the Graafian follicles are going on. If im- 
pregnation does not take place, the ovules are discharged and lost ; if 
it does, ovulation is stopped, as a general rule, during gestation and 
lactation. 

Theory of Menstruation. — This, broadly speaking, is an outline of 
the ovular theory of menstruation, which was first broached in the year 
1821 by Dr. Power, and subsequently elaborated by Negrier, Bisclioif, 
Raciborski, and many other writers. Although the sequence of events 
here indicated may be taken to be the rule, it must be remembered 
that it is one subject to many exceptions, for undoubtedly ovulation mav 
occur without its outward manifestation, menstruation, as in cases in 
which impregnation takes place during lactation, or before menstrua- 
tion has been established, of which many examples are recorded. 
These exceptions have led some modern writers to deny the ovular 



OVULATION AND MENSTRUATION. 

theory of menstruation, and their views will require subsequent con- 
sideration. 

In order to understand the subject properly, it will be accessary to 
study the sequence of events in detail. 

Changes in the Graafian Follicle. — The changes in the Graafian 
follicle which are associated with the discharge of the ovules com- 
prise : 

1. Maturation. As the period of puberty approaches, a certain 
number of the Graafian follicles, fifteen to twenty in uumber, increase 
in size, and come near the surface of the ovary. A.mongs1 these one 
becomes especially developed, preparatory to rupture, and upon it for 
the time being all the vital energy of the ovary seems to he concen- 
trated. A similar change in one, sometimes in more than one, follicle 
takes place periodically during the whole of the childbearing epoch, 
in connection with each menstrual period, and an examination of the 
ovary will show several follicles in different stages of development. 
The maturing follicle becomes gradually larger, until it forms a pro- 
jection on the surface of the ovary, from five to seven lines in breadth, 
but sometimes even as large as a nut (Fig. 34). This growth is due 
to the distention of the follicle by the increase of its contained fluid, 
which causes it so to press upon the ovarian structures covering it that 
they become thinned, separated from each other, and partially absorbed, 
until they eventually readily lacerate. The follicle also becomes greatly 
congested, the capillaries coursing over it become increased in size and 
loaded with blood, and being seen through the attenuated ovarian 
tissue, give it, when mature, a bright-red color. At this time some 
of these distended capillaries in- its inner coat lacerate, and a certain 
quantity of blood escapes into its cavity. This escape of blood takes 
place before rupture, and seems to have for its principal object the 
increase of the tension of the follicle, of which it has been termed the 
menstruation. Pouchet was of opinion that the blood collects behind 
the ovule, and carries it up to the surface of the follicle. 

2. Escape of the ovule. By these means the follicle is more and 
more distended, until at last it ruptures (Plate III., Fig. 1), either 
spontaneously, or, it may be, under the stimulus of sexual excitement. 
Whether the laceration takes place during, before, or after the men- 
strual discharge is not yet positively known ; from the results of post- 
mortem examination in a number of women who died shortly before 
or after the period, "Williams believes that the ovules are expelled 
before the monthly flow commences. 1 In order that the ovule may 
escape, the laceration must, of course, involve not only the coats of the 
Graafian follicles, but also the superincumbent structures. 

Laceration seems to be aided by the growth of the internal layer of 
the follicle, which increases in thickness before rupture 4 , and assumes a 
characteristic yellow color from the number of oil-globules it then 
contains. It is also greatly facilitated, if it be not actually produced, 
by the turgescence of the ovary at each menstrual period, and by the 
contraction of the muscular fibres in the ovarian stroma. As soon as 
the rent in the follicular Avails is produced, the ovule is discharged. 

i Proceedings of the Royal Society, 1875. 



84 



ORGANS CONCERNED IN PARTURITION. 



surrounded by some of the cells of the membraua granulosa, and is 
received into the fimbriated extremity of the Fallopian tube, which 
has been said to grasp the ovary over the site of the rupture. This, 
however, has never been satisfactorily proved to be the case. Henle 
supposed that the ovum is washed into the open extremity of the 
Fallopian tube, by means of currents produced in the peritoneal serum 
by the vibration of the cilia? of the epithelium which covers both 
surfaces of the fimbria?. By the vibratile cilia? of its epithelial lining 
it is then conducted into the canal of the tube, along which it is pro- 
pelled, partly by ciliary action, and partly by muscular contraction in 
the walls of the tube. 

After the ovule has escaped, certain characteristic changes occur in 
the empty Graafian follicle, which have for their object its cicatrization 
and obliteration. There are great differences in the changes which 
occur when impregnation has followed the escape of the ovule, and 
they are then so remarkable that they have been considered certain 
signs of pregnancy. They are, however, differences of degree rather 
than of kind. It will be well, however, to discuss them separately. 

As soon as the ovule is discharged, the edges of the rent through 
which it has escaped become agglutinated by exudation, and the follicle 
shrinks, as is generally believed, by the inherent elasticity of its in- 
ternal coat but according to Robin, who denies the existence of this 
coat, from compression by the muscular fibres of the ovarian stroma. 
In proportion to the contraction that takes place, the inner layer of 
the follicle, the cells of which have become greatly hypertrophied and 
loaded with fat-granules previous to rupture, is thrown into numerous 
folds (Plate III., Fig. 2). Between these, young connective tissue 

begins to form, and vascular offshoots, 
like papilla?, arising from the vascular 
network surrounding the follicles, also 
penetrate the interstices. The greater 
the amount of contraction the deeper 
these folds become, giving to a section of 
the follicle an appearance similar to that 
of the convolutions of the brain (Fig. 41 ). 
These folds in the human subject are 
generally of a bright-yellow color, but 
in some of the mammalia they are of a 
deep red. The tint was formerly ascribed 
by Raciborski to absorption of the color- 
ing matter of the blood-clot contained in 
the follicular cavity, a theory he has 
more recently abandoned in favor of the 
view maintained by Coste, that it is due 
to the inherent color of the cells of the 
membrane of the follicle, which, though not well marked in a 
cell, becomes very apparent en masse. The existence of a con- 
blood-clot is also denied by the latter physiologist, except as 
an unusual pathological condition ; and he describes the cavitv as 
containing a gelatinous and plastic fluid, which becomes absorbed as 




Section of ovary, showing corpus 
luteum three weeks after menstrua- 
tion. (After Dalton.) 



lining 
single 
tained 



Plate II . 








Fig l. 
ArtceA 

- 



Fig. 2. 



J$~ M " "X 








Fig 3 



Fig l. 



ILLUSTRAT1 . TUP. COR1 S TON I 



V L* L A T 1 N AND M K N B T B U ATK 

contraction advances. The more recent researches of I >; 1 1 1 - . 1 1 . l how- 
ever, show the existence of a central blood-clot in the cavity of the 
follicle, and he considers it- occasional absence to be connected with 
disturbance or cessation of the menstrual (unction. The folds into 
which the membrane has been thrown continue to increase in Bize, 
from the proliferation of their cells, until they unite and become 
adherent, and eventually till the follicular cavity. By the time that 
another Graafian follicle i- matured and ready for rupture, the dimi- 
nution lias advanced considerably, and the empty ovisac is reduced to 
a very small size. The cavity is now nearly obliterated, the yellow 
color of the convolutions is altered into a whitish tint, and on section 
the corpus luteum has the appearance «>t' a compact white stellate 
cicatrix, which generally disappears in less than forty days from the 
period of rupture. The tissue of the ..vary at the -in- of laceration 
also shrinks, and this, aided by the contraction of the follicle, gives 
rise t<> one of those permanent pit- or depressions which mark the 
surface of the adult ovary. Slavyansky* ha- shown that only a few 
of the immense number of Graafian follicle- undergo these alterations. 
The greater proportion of them seem never to discharge their ovules, 
l>ut. after increasing in size, undergo retrogressive changes exactly 
similar in their nature, but to a much less extent. to those which 
result in the formation of a corpus luteum. The site- of these may 
afterward be seen as minute stria? in the substance of the ovary. 

Should pregnancy occur, all the changes above described take place ; 
but, inasmuch as the ovary partake- of the stimulus to which all the 
generative organs are then subjected, they are much more marked and 
apparent (Plate III.. Fig. 4). Instead of contracting and disappear- 
ing in a few weeks, the corpus luteum continues to grow until the third 
or fourth month of pregnancy ; the Ibid- of the inner layer of the 
ovisac become large and fleshy, and permeated by numerous capillaries, 
and ultimately become so firmly united that the margins of the con- 
volutions thin and disappear, leaving only a firm Meshy yellow ma—, 
averaging from 1 to li inches in thickness, which surround- a central 
cavity, often containing a whitish hbrillated structure, believed to be 
the remains of a central blood-clot. This was erroneously supposed 
by Montgomery to be the inner layer of the follicle itself, and he con- 
ceived the yellow substance to be a new formation between it and the 
external layer: while Robert Lee thought it was placed external to 
both the external and internal layer-. 

Between the third and fourth months of pregnancy, when the corpus 
luteum has attained its maximum of development (Fig. 42), it forms a 
firm projection on the surface of the ovary, averaging about one inch 
in length and rather more than half an inch in breadth. After this it 
commences to atrophy (Fig. 4-°>). the fat-cells become absorbed, and the 
capillaries disappear. Cicatrization i> not complete until from one to 
two months after delivery. 

On account of the marked appearance of the corpus luteum. it was 
formerly considered to be an infallible -inn of pregnancy : and it was 

1 '• Report on the Corpus Luteum." American Gynec. Tra: - 577 ii. p. 111. 

• Archiv de Phys.. March. 1-74. 



86 OKGAXS CONCERNED IN PARTURITION. 

distinguished from the corpus luteum of the non-pregnant state bv 
being called a " true " as opposed to a " false " corpus luteum. From 
what has been said it will be obvious that this designation is essentially 
wrong, as the difference is one of degree only. Dalton 1 applies the 
term " false corpus luteum " to a degenerated condition sometimes met 
with in an unruptured Graafian follicle consisting in reabsorption of 
its contents and thickening of its walls (Plate III., Fig. 3). It differs 
from the "true" corpus luteum in being deeply seated in the substance 
of the ovary, in having no central clot, and in being unconnected with 
a cicatrix on the surface of the ovary. Xor do obstetricians attach by 
any means the same importance as they did formerly to the presence of 
the corpus luteum as indicating impregnation ; for even when well 
marked, other and more reliable signs of recent delivery, such as 
enlargement of the uterus, are sure to be present, especially at the time 
when the corpus luteum has reached its maximum of development ; 
while after delivery at term it has no longer a sufficiently characteristic 
appearance to be depended on. 

Fig. 42. Fig. 43. 





Corpus luteum of the fourth month of pregnancy Corpus luteum of pregnancy at 

(After D altox.) term. (After Dalton.) 

Menstruation. — By the term menstruation (catamenia, periods, etc.) 
is meant the periodical discharge of blood from the uterus which 
occurs, in the healthy woman, every lunar month, except during preg- 
nancy and lactation, when it is, as a rule, suspended. 

The first appearance of menstruation coincides with the establish- 
ment of puberty, and the physical changes that accompany it indicate 
that the female is capable of conception and childbearing, although 
exceptional cases are recorded in which pregnancy occurred before 
menstruation had begun. In the temperate climates it generally com- 
mences between the fourteenth and sixteenth years, the largest number 
of cases being met with in the fifteenth year. This rule is subject to 
many exceptions, it being by no means very rare for menstruation to 
become established as early as the tenth or eleventh year, or to be 

i Op. cit.,p. 64. 



OVULATION AND MENSTRUATION. 87 

delayed until the eighteenth or twentieth. Beyond these physiological 
limits a few cases are from time to time met with in which it has begun 
iu early infancy, or not until a comparatively late period of life. 

Influence of Climate, Race, etc. — Various accidental circumstances 
have much to do with its establishment As a rule it occurs somewhat 
earlier in tropical, and later in very cold than in temperate climate-. 
The influence of climate has been unduly exaggerated. It used to be 
generally stated that in the Arctic regions women did not menstruate 
until they were of mature age, and that in the tropics girls of ten or 
twelve years of age did so habitually. The researches of Robertson, 
of Manchester, 1 first showed that the generally received opinions were 
erroneous; and the collection of a large number of statistics has cor- 
roborated his opinion. There can be no doubt, however, that a larger 
proportion of girls menstruate early in warm climates. Joulin found 
that in tropical climates, out of 1635 cases, the largest proportion began 
to menstruate between the twelfth and thirteenth years ; so that there 
is an average difference of more than two years between the period of 
its establishment in the tropics and in temperate countries. Harris 2 
states that among the Hindoos 1 to 2 per cent, menstruate as earlv as 
nine years of age ; 3 to 4 per cent, at ten ; 8 per cent, at eleven; and 
25 per cent, at twelve ; while in London or Paris probably not more 
than one girl in 1000 or 1200 does so at nine years. The converse 
holds true with regard to cold climates, although we are not in pos- 
session of a sufficient number of accurate statistics to draw very reliable 
conclusions on this point ; but out of 4715 cases, including returns from 
Denmark, Norway and Sweden, Russia, and Labrador, it was found 
that menstruation was established on an average a year later than in 
more temperate countries. It is probable that the mere influence of 
temperature has much to do in producing these differences, but there are 
other factors, the action of which must not be overlooked. Raciborski 
attributes considerable importance to the effect of race ; and he has 
quoted Dr. Webb, of Calcutta, to the effect that English girls in India, 
although subjected to the same climatic influence as the Indian races, 
do not, as a rule, menstruate earlier than in England ; while, in Austria, 
girls of the Magyar race menstruate considerably later than those of 
German parentage. 3 The surroundings of girls, and their manner of 
education and living, have probably also a marked influence in pro- 
moting or retarding its establishment. Thus, it will commence earlier 
in the children of the rich, who are likely to have a highly developed 
nervous organization, and are habituated to luxurious living, and a 
premature stimulation of the mental faculties by novel-reading, society, 
and the like; while amongst the hard-worked poor, or in girls brought 
up in the country, it is more likely to begin later. Premature sexual 
excitement is said also to favor its early appearance, and the influence 
of this among the factory girls of Manchester, who are exposed in the 
course of their work to the temptations arising from the promiscuous 
mixing of the sexes, has been pointed otit by Dr. Clay. 4 

1 Edin. Med. and Pun?. Journ., 1832. 

2 Amer Journ. of Obstet., 1870-71, vol. iii. p. fill. R. P. Harris "On Earlv Pubertv." 

3 Op. cit., p. 227. 4 Brit. Record of Obstet. Med., voi. i. 



88 ORGANS CONCERNED IN PARTURITION. 

[Precocious Physical Womanhood. — AVe emphasize the term 
"physical," because in a mental and moral sense the subjects are for- 
tunately, with rare exceptions, only children in years and tastes. Pre- 
cociously developed girls are, as a rule, of very unusual size for their 
years, and usually enjoy good health, while precocity in male children 
is apt to be associated with semi-idiocy and epilepsy. AVhere men- 
struation begins in the first year, the girl may at three or four years 
of age present the evidences of puberty in the appearance of pubic 
and axillary hair, rounded mamma?, and a broad pelvis, associated 
with well-rounded arms and legs and a strength and height much 
beyond her years. In three children born in this State, these charac- 
teristics were marked, respectively, at four and a half years, five, and 
six. The five-year-old girl was a beautifully formed miniature woman, 
and the one of six was large, fat, and had the developed features of 
twice her age ; still, she was only a child in tastes, and as such devoted 
to her dolls and toys. The sexual passion is very rarely a marked 
characteristic in such subjects, as it is in the other sex, and hence the 
ability to procreate has rarely been tested ; but occasionally in the 
lower classes pregnancy has occurred at an early age. 

The youngest English mother on record was nine years seven months 
and nine days old when Mr. Henry Dodd, of Billington, York, who 
was present at her birth, delivered her of a seven-pound healthy child, 
after a labor of six hours, on March 17, 1881. She commenced to 
menstruate at twelve months, and became pregnant about six weeks 
before she was nine years old. 1 

The youngest American mother became such at ten years and thir- 
teen days, giving birth to a child of seven and three-quarters pounds. 
She also menstruated at one year, and at the time of her labor was 
four feet seven inches in height and weighed one hundred pounds. 
The case was reported by Dr. Eowlett, of Kentucky. 2 A still younger 
mother was reported by Schmitt more than a century ago. The child 
began to menstruate at two years, and when eight years and ten 
months old bore a dead foetus which was thought by its development 
to have reached its full term. The mother had the mamma? and pubes 
of a girl of seventeen. 3 — Ed.] 

Chang-es Occurring- at Puberty. — The first appearance of men- 
struation is accompanied by certain well-marked changes in the female 
system, on the occurrence of which we say that the girl has arrived at 
the period of puberty. The pubes become covered with hair, the 
breasts enlarge, the pelvis assumes its fully developed form, and the 
general contour of the body fills out. The mental qualities also alter ; 
the girl becomes more* shy and retiring, and her whole bearing indi- 
cates the change that has taken place. The menstrual discharge is not 
established regularly at once. For one or two months there mav be 
only premonitory symptoms — a vague sense of discomfort, pains in 
the breasts, aud a feeling of weight and heat in the back and loins. 
There then may be a discharge of mucus tinged with blood, or of 

1 Barnes's Obstetric Medicine and Surgery.] 
- Transylvania Med. Journ.. vol. vii. p. 447.] 
3 Sue's Essais historiques, Paris, 1779, vol. ii. p. 344.] 



OVULATION' AND MENSTRUATION. 89 

pure blood, and this may not again show- Itself for Beveral months. 
Such irregularities are of little consequence on the first establishment 
of the function, and need give rise to do apprehension. 

Duration. — Asa rule, the discharge recur- every twenty-eight days, 
and with some women with such regularity that they can foretell its 
appearance almost to the hour. The rule is, however, subject to very 

great variations. It is by no means uncommon, and strictly within 
the limits of health, for it to appear every twentieth day. or even with 
less interval; while in other eases as much as six weeks may habitu- 
ally intervene between two periods. The period of recurrence may 
also vary in the same subject. I am acquainted with patients who 
sometimes only have twenty-eight days, at others as many as forty- 
eight days, between their periods, without their health in any way 
suffering. Joulin mentions the ease of a lady who only menstruated 
two or three times in the year, and whose sister had the same pecu- 
liarity. 

The duration of the period varies in different women, and in the 
same woman at different times. In this country its average is four or 
five days, while in France, Dubois and Brierre de Boismont fix eight 
days as the most usual length. Some women are only unwell for a 
few hours, while in others the period may last many days beyond the 
average without being considered abnormal. 

The quantity of blood lost varies in different women. Hippocrates 
puts it at gxviij, which, however, is much too high an estimate. 
Arthur Farre thinks that from §ij to 5iij is the full amount of a 
healthy period, and that the quantity cannot habitually exceed this 
without producing serious constitutional effects. Rich diet, luxurious 
living, and anything that unhealthily stimulates the body and mind, 
will have an injurious effect in increasing the flow, which is, therefore, 
less in hard-worked countrywomen than in the better classes and 
residents in towns. 

It is more abundant in warm climates, and our countrywomen in 
India habitually menstruate over-profusely, becoming less abundantly 
unwell when they return to England. The same observation has been 
made with regard to American women residing in the Gulf States, who 
improve materially by removing to the Lake States. Some women 
appear to menstruate more in summer than in winter. I am acquainted 
with a lady who spends the winter in St. Petersburg, where her periods 
last eight or ten days, and the summer in England, where they never 
exceed four or five. The difference is probably due to the effect of the 
overheated rooms in which she lives in Russia. 

The daily loss is not the same during the continuance of the period. 
It generally is at first slight, and gradually increases so a- to be most 
profuse on the second or third day, and as gradually diminishes. 
Toward the last days it sometime- disappears for a few hour-, and 
then comes on again, and is apt to recur under any excitement or 
emotion. 

As the menstrual fluid escapes from the uterus it consists of pure 
blood, and if collected through the speculum, it coagulates. The 
ordinarv menstrual fluid does not coagulate unless it i< excessive in 



90 ORGANS CONCERNED IN PARTURITION. 

amount. Various explanations of this fact have been given. It was 
formerly supposed either to contain no fibrin, or an unusually small 
amount. Retzius attributes its non-coagulation to the presence of free 
lactic and phosphoric acids. The true explanation was first given by 
Mandl, who proved that even small quantities of pus or mucus in 
blood were sufficient to keep the fibrin in solution ; and mucus is 
always present to greater or less amount in the secretions of the cervix 
and vagina, which mix with the menstrual blood in its passage through 
the genital tract. If the amount of blood be excessive, however, the 
mucus present is insufficient in quantity to produce this effect, and 
coagula are then formed. 

On microscopic examination the menstrual fluid exhibits blood 
corpuscles, mucous corpuscles, and a considerable amount of epithelial 
scales, the last being the debris of the epithelium lining the uterine 
cavity. According to Virchow, the form of the epithelium often 
proves that it comes from the interior of the utricular glands. The 
color of the blood is at first dark, and as the period progresses it gen- 
erally becomes lighter in tint. In women who are in bad health it is 
often very pale. These differences doubtless depend upon the amount 
of mucus mingled with it. The menstrual blood has always a char- 
acteristic faint and heavy odor, which is analogous to that which is 
so distinct in the lower animals during the rut. Raciborski mentions 
a lady who was so sensitive to this odor that she could always tell to 
a certainty when any woman was menstruating. It is attributed either 
to decomposing mucus mixed with the blood, which, when partially 
absorbed, may cause the peculiar odor of the breath often perceptible 
in menstruating women ; or to the mixture with the fluid of the 
sebaceous secretion from the glands of the vulva. It probably gave 
rise to the old and prevalent prejudices as to the deleterious properties 
of menstrual blood, which, it is needless to say, are altogether without 
foundation. 

It is now universally admitted that the source of the menstrual 
blood is the mucous membrane lining the interior of the uterus, for 
the blood may be seen oozing through the os uteri by means of the 
speculum, and in cases of prolapsus uteri ; while in cases of inverted 
uterus it may be actually observed escaping from the exposed mucous 
membrane, and collecting in minute drops upon its surface. During 
the menstrual nisus the whole mucous lining becomes congested to 
such an extent that, in examining the bodies of women who have died 
during menstruation, it is found to be thicker, larger, and thrown into 
folds, so as to completely fill the uterine cavity. The capillary cir- 
culation at this time becomes very marked, and the mucous membrane 
assumes a deep-red hue, the network of capillaries surrounding the 
orifices of the utricular glands being especially distinct. These facts 
have an unquestionable connection with the production of the dis- 
charge, but there is much difference of opinion as to the precise mode 
in which the blood escapes from the vessels. Coste believed that the 
blood transudes through the coats of the capillaries without any 
laceration of their structure. Farre inclines to the hypothesis that the 
uterine capillaries terminate by open mouths, the escape of blood 



OVULATION AND MENSTRUATION. 91 

through these, between the menstrual periods, being prevented by 
muscular contraction of the uterine walls. Pouchet believed thai 
during each menstrual epoch the entire mucous membrane is broken 

down and cast off in the form of minute shreds, a fresh muCOUS mem- 
brane being developed in the interval between two periods. During 
this process the capillary network would be laid hare and ruptured, 
and the escape of blood readily accounted for. Tyler Smith, who 
adopted this theory, states that he has frequently seen the uterine 
mucous membrane, in women who have died during menstruation, in 
a state of dissolution, with the broken loops of the capillaries exposed. 
The phenomena attending the so-called membranous dysmenorrhea, 
in which the mucous membrane is thrown off in shreds, or as a cast 
of the uterine cavity — the nature of which was first pointed out by 
Simpson and Oldham — have been supposed to corroborate this theory. 
This view is, in the main, • corroborated by the recent researches of 
Engelmann, 1 Williams, 2 and others. Williams describes the mucous 
lining of the uterus as undergoing a fatty degeneration before each 
period, which commences near the inner os, and extends over the whole 
mucous membrane, and down to the muscular wall. This seems to 
bring oh a certain amount of muscular contraction, which drives the 
blood into the capillaries of the mucosa, and these, having become 
degenerated, readily rupture, and permit the escape of the blood. The 
mucous membrane now rapidly disintegrates, and is cast off in shreds 
with the menstrual discharge, in which masses of epithelial cells may 
always be detected. Engelmann, however, holds that the fatty degen- 
eration is limited to the superficial layers, and that a portion only of 
the epithelial investment is thrown off. As soon as the period is over, 
the formation of a new mucous membrane is begun, which arises either 
from proliferation of the elements of the muscular coat itself, or from 
the proliferation of the epithelial cells lining the bases of the uterine 
glands which remain imbedded in the muscular tissue after the mucous 
membrane has been thrown off, and at the end of a Aveek the whole 
uterine cavity is lined by a thin mucous membrane. This grow r s until 
the advent of another period, when the same degenerative changes 
occur unless impregnation has taken place, in which case it becomes 
further developed into the decidua. Lowenthal 3 believes that the 
menstrual decidua is produced by the imbedding of an ovum in the 
lining membrane of the uterus, which, if impregnation occurs, is 
developed into the decidua of pregnancy. If conception docs not 
take place, the ovum dies, and this is followed by the degeneration 
and expulsion of the menstrual decidua, accompanied by a flow r of 
blood, which is the menstrual discharge. 

Theory of Menstruation. — That there is an intimate connection 
between ovulation and menstruation is admitted by most physiologists, 
and it is held by many that the determining cause of th< discharge is 
the periodic maturation of the Graafian follicles. There is abundant 

1 American Journal of Obstetrics, 1875-76. vol. viii. p. 30. 

2 "On the Structure of the Mucous Membrane of the Uterus," Obstet. Journ.. 1S7.V76, vol. in. 
p. 496. 

3 Arch, f Gvn., Bd. xxiv., Heft 2, S. 169: "Eine neue Deutung des Menstruations-Prozess." 



92 ORGANS CONCERNED IN PARTURITION. 

evidence of this connection, for we know that when, at the change of 
life, the Graafian follicles cease to develop, menstruation is arrested ; 
and when the ovaries are removed by operation, of which there are now 
numerous cases on record, or when they are congenitally absent, men- 
struation does not generally take place. A few cases, however, have 
been observed in which menstruation continued after double ovari- 
otomy, or the removal of the ovaries by Battey's operation, and these 
have been used as an argument by those physiologists who doubt the 
ovular theory of menstruation. Slavvansky has particularly insisted 
on such cases, which, however, are probably susceptible of explanation. 
It may be that the habit of menstruation may continue for a time even 
after the removal of the ovaries ; and it has not been shown that men- 
struation has continued permanently after double ovariotomy, although 
it certainly has occasionally, although quite exceptionally, done so for 
a time. It is possible, also, that in such cases a small portiou of ovarian 
tissue may have been left unremoved, sufficient to carry on ovulation. 
Roberts, a traveller quoted by Depaul and Gueniot in their article on 
Menstruation in the JDictionnaire des Sciences 31edicales, relates that in 
certain parts of Central Asia it is the custom to remove both ovaries in 
young girls who act as guards to the harems. These women, known 
as "hedjeras," subsequently assume much of the virile type, and never 
menstruate. The same close connection between ovulation and the rut 
of animals is observed, and supports the conclusion that the rut and 
menstruation are analogous. The chief difference between ovulation 
in man and the lower animals is that in the latter the process is not 
generally accompanied by a sanguineous flow. To this there are excep- 
tions, for in monkeys there is certainly a discharge analogous to men- 
struation occurring at intervals. 

Another point of distinction is that in animals connection never 
takes place except during the rut, and that it is then only that the 
female is capable of conception ; Avhile in the human race conception 
only occurs in the interval between the periods. This is another argu- 
ment brought against the ovular theory, because, it is said, if menstrua- 
tion depend on the rupture of a Graafian follicle and the emission of 
an ovule, then impregnation should only take place during or imme- 
diately after menstruation. Coste explains this by supposing that it is 
the maturation and not the rupture of the follicle which determines the 
occurrence of menstruation ; and that the follicle may remain unrup- 
tured for a considerable time after k is mature, the escape of the ovule 
being subsequently determined by some accidental cause such as sexual 
excitement. However this may be, there is good reason to believe that 
the susceptibility to conception is greater during the menstrual epochs. 
Eaciborski believes that in the large proportion of cases impregnation 
occurs in the first half of the menstrual interval, or in the few davs 
immediately preceding the appearance of the discharge. There are, 
however, very numerous exceptions, for in Jewesses, who almost inva- 
riably live apart from their husbands for eight days after the cessation 
of menstruation, impregnation must constantly occur at some other 
period of the interval, and it is certain that they are not less prolific 
than other people. This rule with them is very strictly adhered to, as 



OVULATION AND MENSTRUATION. 98 

will be seen by the accompanying interesting letter from a medical 
Mend who is a well-known member of that community , and \\ hich I 
have permission to publish. 1 This fad is of itself sufficient to disprove 
the theory advanced by Dr. A.vrard, 2 thai impregnation is Impossible 
in the latter half of the menstrua] interval. This, and the other reasons 
referred to, undoubtedly throw some doubt on the ovular theory, but 
they do not seem to be sufficient to justify the conclusion that men- 
struation is a physiological process altogether independent of tin' 
development and maturation of the Graafian follicles. All that they 
can be fairly held to prove is that the escape of the ovules may occur 
independently of menstruation, but the weight of evidence remain- 
strongly in favor of the theory which is generally received. 

It should be stated that several recent writers, Law son Tail amongst 
the number, attribute considerable influence in menstruation to tne 
Fallopian tubes. Robinson, of Chicago, in an interesting paper, 3 con- 
tends that menstruation is governed by nervous ganglia situated in the 
walls of the Fallopian tubes and uterus, which he calls "automatic 
menstrual ganglia." These he considers to be analogous to the nerve 
ganglia found iu the heart, intestines, and other hollow viscera, and to 
have the function of producing rhythmical peristalsis in the tubes, 
which favors the passage of the ovum along their canal. He believes 
that ovulation is entirely unconnected with menstruation, and goes on 
independently of it, the greater part of the ovules being lost in the 
peritoneal cavity ; and that it is only when the periodic and rhythmical 
action of the tubes begins that menstruation is established. These 
views cannot be taken as proved, but they certainly suggest an explana- 
tion of some of the phenomena of menstruation otherwise difficult to 
understand, such as its occasional continuance after the removal of the 
ovaries, and are well worthy of further investigation. 

The cause of the monthly periodicity is quite unknown, and will 
probably always remain so. Goodman 4 has suggested what he calls the 
" cyclical theory of menstruation," which refers the phenomena to a 

1 10 Bernard Street, Russell Square, July 21, is:;. 
My dear Sir: 1. To the best of my knowledge and belief, the law which prohibits sexual 
intercourse among Jews for seven clear days after the cessation of menstruation, is almost 
universally observed, the exceptions not being sufficient to vitiate statistics. The law has perhaps 
fewer exceptions on the Continent— especially Russia and Poland, where the Jewish population is 
very great— than in England. Even here, however, women who observe no other ceremonial law- 
observe this, and cling to it after everything else is thrown overboard. There are doubtless many 
exceptions, especially among the better classes in England, who keep only three days after the 
cessation of the menses. 

2. The law is— as you state— that should the discharge last only an hour or so. or should there be 
only one gush or one spot on the linen, the rive days during which the period might continue are 
observed; to which must be superadded the seven clear days— twelve days per mensem in which 
connection is disallowed. Should any discharge be seen in the inter-menstrual period, seven days 
would have to be kept, but not the five, for such irreffnUar discharge. 

3. The "bath of purification," which must contain at least eighty gallons, is used on the last 
night of the seven clear days. It is not used till after a bath for cleansing purposes; and, from 
the night when such "purifying" bath is used, Jewish women are accustomed to calculate the 
commencement of pregnancy. That you should not have heard it is not strange; its mention 
would be considered highly indelicate. 

4. Jewish women reckon their Dregnancy to last nine calendar or ten lunar months— 270 to 280 
days. There are no special data on winch to reckon an average, nor do I know of any lw»ok> on 
the subject, except some Talmurlic authorities, which I will look up for you it' you desire it. Pray 
make no anologies for writing to me : any information I possess Is at your service. 

1 am, dear Sir, yours very truly. 
Dr. Playfair. A. Asher. 

P. S.— The Biblical foundation for the law of the seven clear days is Leviticus xv.. verse L9 till 
the end of the chapter— especially vers 

2 Rev. de Therap. Mt-d.-Chir., 1867. 

3 American Journal of Obstetrics, Sept. 1S91. 4 Ibid., 1878, vol. xi. p 



94 ORGANS CONCERNED IN PARTURITION. 

general condition of the vascular system, specially localizing itself in 
the generative organs, and connected with rhythmical changes in their 
nerve-centres. It does not seem to me, however, that he has satis- 
factorily proved the recurrence of the conditions which his ingenious 
theory assumes. The purpose of the loss of so much blood is also 
semewhat obscure. To a certain extent it must be considered an acci- 
dent or complication of ovulation, produced by the vascular turgescence. 
Nor is it essential to fecundation, because women often conceive during 
lactation, when menstruation is suspended ; or before the function has 
become established. It may, however, serve the negative purpose of 
relieving the congested uterine capillaries which are periodically filled 
with a supply of blood for the great growth which takes place when 
conception has occurred. Thus, immediately before each period the 
uterus may be considered to be placed by the afflux of blood in a state 
of preparation for the function it may suddenly be called upon to per- 
form. That the discharge relieves a state of vascular tension which 
accompanies ovulation is proved by the singular phenomenon of 
vicarious menstruation which is occasionally, though rarely, met with. 
It occurs in cases in which, from some unexplained cause, the discharge 
does not escape from the uterine mucous membrane. Under such cir- 
cumstances a more or less regular escape of blood may take place from 
other sites. The most common situations are the mucous membranes 
of the stomach, of the nasal cavities, or of the lungs ; the skin, not 
uncommonly that of the mamma?, probably on account of their intimate 
sympathetic relation with the uterine organs ; from the surface of an 
ulcer ; or from hemorrhoids. It is a noteworthy fact that in all these 
cases the discharge occurs in situations where its external escape can 
readily take place. This strange deviation of the menstrual discharge 
may be taken as a sign of general ill-health, and it is usually met with 
in delicate young women of highly mobile nervous constitution. It 
may, however, begin at puberty, and it has even been observed during 
the whole sexual life. The recurrence is regular, and always in con- 
nection with the menstrual nisus, although the amount of blood lost is 
much less than in ordinary menstruation. 

Cessation of Menstruation. — After a certain lime changes occur, 
showing that the woman is no longer fitted for reproduction ; men- 
struation ceases, Graafian follicles are no longer matured, and the ovary 
becomes shrivelled and wrinkled on its surface. Analogous alterations 
take place in the uterus and its appendages. The Fallopian tubes 
atrophy, and are not unfrequently obliterated. The uterus decreases 
in size. The cervix undergoes a remarkable change, which is readily 
detected on vaginal examination ; the projection of the cervix into the 
vaginal canal disappears, and the orifice of the os uteri in oil women 
is found to be flush with the roof of the vagina. In a large number 
of cases there is, after the cessation of menstruation, an occlusion both 
of the external and internal os ; the canal of the cervix between them, 
however, remains patulous, and is not unfrequentlv distended with a 
mucous secretion. 

Period of Cessation. — The age at which menstruation ceases varies 
much in different women. In certain cases it may cease at an unusually 






OVULATION AND MENSTRUATION. 

early ago, as between thirty and forty years, or it may continue far 
beyond the average time, even up to sixty years; and exceptional, 
though perhaps hardly reliable, instances are recorded, in which if has 
continued even to eighty or ninety years. These are, however, strange 

anomalies, which, like cases of unusually precocious menstruation, 
cannot be considered as having any hearing on the general rule. Most 
cases of so-called protracted menstruation will be found to be really 

morbid losses of blood depending on malignant or Other forms of 
Organic disease, the existence of which, under such circumstances, 
should always be suspected. 

In England menstruation usually ceases between forty and fifty 
years of age. Kaeiborski says that the largest number of eases of 
cessation are met with in the forty-sixth year. Jt is generally said 
that women who commence to menstruate when very young cease to 
do so at a comparatively early age, so that the average duration of the 
function is about the same in all women. Cazeaux and Raciborski, 
whose opinion is strengthened by the observations of Guv in 1500 
eases, 1 think, on the contrary, that the earlier menstruation commences 
the longer it lasts, early menstruation indicating an excess of vital 
energy which continues during the whole childbearing life. Climate 
and other accidental causes do not seem to have as much effect on the 
cessation as on the establishment of the function. It does not appear 
to cease earlier in warm than in temperate climates. The change of 
life is generally indicated by irregularities in the recurrence of the 
discharge. It seldom ceases suddenly, but it may be absent for one or 
more periods, and then occur irregularly; or it may become profuse 
or scanty, until eventually it entirely stops. The popular notions as 
to the extreme danger of the menopause are probably much exagger- 
ated ; although it is certain that at that time various nervous phenomena 
are apt to be developed. So far from having a prejudicial effect on 
the health, however, it is not an uncommon observation to see an 
hysterical woman, who has been for years a martyr to uterine and 
other complaints, apparently take a new lease of life when her uterine 
functions have ceased to be in active operation ; and statistical tables 
abundantly prove that the general mortality of the sex is not greater 
at this than at any other time. 

1 Med. Times and Gaz., 1845. 



PART II 

PREGNANCY. 



CHAPTEE I. 

CONCEPTION AND GENERATION. 

Generation in the human female, as in all mammals, requires the 
congress of the two sexes, in order that the semen, the male element 
of generation, may be brought into contact with the ovule, the female 
element of generation. 

The Semen. — The semen secreted by the testicle of an adult male 
is a viscid, opalescent fluid, forming an emulsion when mixed with 
water, and having a peculiar faint odor, which is attributed to the 
secretions which are mixed with it, such as those from the prostate 
and Cowper's glands. On analysis it is found to be an albuminous 
fluid, holding in solution various salts, principally phosphates and 
chlorides, and an animal substance, spermatin, analogous to fibrin. 
Examined under a magnifying power of from 400 to 500 diameters, 
it consists of a transparent and homogeneous fluid, in which are 
floating a certain number of granules and epithelial cells, derived from 
the secretions mixed with it, and certain characteristic bodies, the 
spermatozoa, which are developed from the sperm cells, and which 
form its essential constituents. The sperm cells are those occupying 
the tubuli seminiferi of the testicle. Several kinds of sperm cells 
are described, which receive their name from the position they occupv 
with regard to the lumen of the tubule (Fig. 44). The ceils which 
are next to the wall of the tubule are called the outer or lining cells. 
They are more or less flattened in form, and are situated on a distinct 
basement membrane. Internal to this layer is another, consisting of 
round cells, the nuclei of which are in a state of proliferation ; this is 
the intermediate layer. Between this and the lumen of the tubule are 
a number of cells, irregular in shape, amongst which are imbedded 
the heads of the spermatozoa, the tails of which project into the lumen. 
The spermatozoa are thought to arise from the middle or proliferating 
layer in the following manner : the nuclei of the sperm cells pro- 
liferate, and from their subdivisions arise the heads of the spermatozoa, 
the bodies of which originate from the protoplasm of the cells. Bv 
the decomposition of the substance in which the heads of the sperma- 
tozoa are imbedded, the contained spermatozoa become liberated, and 
move about freelv in the seminal fluid. 



CONCEPTION A \ i> GENERATION. 



97 



As seen under the microscope, the spermatozoa, which exist in 
healthy semen in enormous numbers, present the appearance of minute 
particles, not unlike a tadpole in shape. The head is oval and flat- 
tened, measuring about To - ( 1 nnT of an inch in breadth, and attached in 

it by a short intermediate portion is a delicate filamentous expansion 
or tail, which tapers to a point so line that it- termination cannot be 
seen by the highest powers of the microscope. The whole sperma- 
tozoon measures from -^ to ^-J-^ of an inch in Length. The sperma- 
tozoa are observed to be in constant motion, sometimes very rapid, 
sometimes more gentle, which is supposed to be the means by which 

Fig. 44. 




Section of parts of three seminiferous tubules of the rat. a. With the spermatozoa least advanced 
in development, b. More advanced, c. Containing fully-developed spermatozoa. Between the 
tubules are seen strands of interstitial cells and lymph spaces. (From a preparation by MB. A. 
Fkazer. ) 



they pass upward through the female genital organs. They retain 
their vitality and power of movement for a considerable time after 
emission, provided the semen is kept at a temperature similar to that 
of the body. Under such circumstances they have been observed in 
active motion from forty-eight to seventy-two hours after ejaculation, 
and they have also been seen alive in the testicle as long as twenty- 
four hours after death. In all probability they continue active much 
longer within the generative organs, as many physiologists have 
observed them in full vitality in bitches and rabbits, seven or eight 
days after copulation. The recent experiments of Haussman, how- 
ever, show that they lose their power of motion in the human vagina 
within twelve hours after coitus, although they doubtless retain it 
longer in the uterus and Fallopian tubes. Abundant leucorrhoeal dis- 
charges and acrid vaginal secretions destroy their movements, and may 
thus cause sterility in the female. On account of their mobility, the 
spermatozoa were long considered to be independent animalcules, a 
view which i- by no means exploded, and has been maintained in 



98 PREGNANCY. 

modern times by Pouchet, Joulin, and other writers, while Coste, 
Robin, Kolliker, etc., liken their motion to that of ciliated epithelium. 
There can be no doubt that the fertilizing power of the semen is due 
to the presence of the spermatozoa, although some of the older physi- 
ologists assigned it to the spermatic fluid. The former view, however, 
has been conclusively proved by the experiments of Prevost and 
Dumas, who found that on carefully removing the spermatozoa by 
filtration the semen lost its fecundating properties. 

Sites of Impregnation. — There has been great difference of opinion 
as to the part of the genital tract in which the spermatozoa and the 
ovule come into contact, and in which impregnation, therefore, occurs. 
Spermatozoa have been observed in all parts of the female genital 
organs in animals killed shortly after coitus, especially in the Fallopian 
tubes, and even on the surface of the ovary. The fact that fecundation 
has been proved to occur in certain animals within the ovary, tends to 
support the idea that it may also occur in the human female before the 
rupture of the Graafian follicle. In order to do so, however, it is 
necessary for the spermatozoa to penetrate the proper structure of the 
follicle and the epithelial covering of the ovary, and no one has actu- 
ally seen them doing so. Most probably the contact of the spermatozoa 
and the ovule occurs very shortly after the rupture of the follicle, and 
in the outer part of the Fallopian tubes. Coste maintains that, unless 
the ovule is impregnated, it very rapidly degenerates after being 
expelled from the ovary, partly by inherent changes in the ovule 
itself, and partly because it then soon becomes invested by an albu- 
minous covering which is impermeable to the spermatozoa. He 
believes, therefore, that impregnation can only occur either on the 
surface of the ovary, or just within the fimbriated extremity of the 
tube. 

Mode in which the Ascent of the Semen is Effected. — The semen 
is probably carried upward chiefly by the inherent mobility of the 
spermatozoa. It is believed by some that this is assisted by other 
agencies : amongst them are mentioned the peristalti 3 action of the 
uterus and Fallopian tubes ; a sort of capillary attraction effected when 
the walls of the uterus are in close contact, similar to the movement of 
fluid in minute tubes ; and also the vibratile action of the cilia of the 
epithelium of the uterine mucous membrane. The action of the latter 
is extremely doubtful, for they are also supposed to effect the descent 
of the ovule, and they can hardly act in two opposite ways. The 
movement of the cilia being from within outward, it would certainly 
oppose rather than favor the progress of the spermatozoa. It must, 
therefore, be admitted that they ascend chiefly through their own 
powers of motion. They certainly have this power to a remarkable 
extent, for there are numerous cases on record in which impregnation 
has occurred without penetration, and even when the hymen was quite 
entire, and in which the semen has simply been deposited on the 
exterior of the vulva ; in such cases, which are far from uncommon, 
the spermatozoa must have found their way through the whole length 
of the vagina. It is probable, however, that under ordinary circum- 
stances the passage of the spermatic fluid into the uterus is facilitated 



CONCEPTION AND GENERATION. 



99 



by changes which take place in the cervix during the sexual orgasm, in 
the course of which the os uteri is said to dilate and close again in a 
rhythmical manner. 1 

Impregnation. — The precise method in which the spermatozoa effeel 
impregnation was long a matter of doubt. It is now, however, certain 
that they actually penetrate the ovule, and reach its interior. This has 
been conclusively proved by the observations of Barry, Meissner, and 
others, who have seen the spermatozoa within the external membrane 
of the ovule in rabbits (Fig. 45). In some of the invertebrata a canal 
or opening, called the micropyle, exists in the zona pellucida, through 
which the spermatozoa pass. No such aperture has yel been demon- 
strated in the ovules of mammals, but in existence is far from improb- 
able. According to the observations of Newport, several spermatozoa 
penetrate the zona pellucida and enter the ovule, and the greater the 
number that do so the more certain fecundation becomes. In the lower 
animals the fusion of the spermatozoa with the substance of the yelk 
has been observed, and although similar phenomena have not been de- 
tected in the human ovum, there is not any doubt but that the further 
development of the ovum is due to the union of the spermatozoa with 
the female element. 

The length of time which elapses before the fecundated ovule arrives 
in the cavity of the uterus has not yet been ascertained, and it probably 
varies under different circumstances. It is 
known that in the bitch it may remain eight FlG - 45 - 

or ten days in the Fallopian tube, in the 
guinea-pig three or four. In the human 
female the ovum has never been discovered 
in the cavity of the uterus before the tenth 
or twelfth day after impregnation. 

The changes which occur in the human 
ovule immediately before and after impreg- 
nation, and during its progress through the 
Fallopian tube, are only known to us by 
analogy, as, of course, it is impossible to 
study them by actual observation. We are 
in possession, however, of accurate informa- 
tion of what has been made ottt in the lower 
animals, and it is reasonable to suppose 
that similar changes occur in man. Imme- 
diately after the ovule has passed into the Fallopian tube, it is found to 
be surrounded by a layer of granular cells, a portion of the lining 
membrane of the Graafian follicle, which was described as the discus 
proligerus. As it proceeds along the tube these surrounding cells dis- 
appear, partly, it is supposed, by friction on the walls of the tube, and 
partly by being absorbed to nourish the ovule. Be this as it may, 
before long thev are no longer observed, and the zona pellucida forms 
the outermost layer of the ovule. When the ovule has advanced some 
distance along the tube, it becomes invested with a covering of albu- 




Ovum of rabbit containing sper- 
matozoa. 1. Zona pellucida. 2. The 
germ, consisting of two large cells, 
several smaller cells, and sperma- 
tozoa. 



How do the Spermatozoa Enter the Uterus? " By J. Beck, M.D. 



100 



PREGNANCY. 



Fig. 46. 




ruinous material, which is deposited around it in successive layers, the 
thickness of which varies in different animals. It is very abundant 
in birds, in whom it forms the familiar white of the egg. In some 
animals it has not been detected, so that its presence in the human 
ovule is uncertain. Where it exists it doubtless contributes to the 
nourishment of the ovule. 

Coincident with these changes is the disappearance of the germinal 
vesicle. At the same time the yelk contracts and becomes more solid ; 
retiring from close contact with the zona pellucida, and thus leaving 
a space, between the outer edge of the yelk and the vitelline membrane, 

which in some animals is filled with 
a transparent liquid. Coincident with 
the shrinking of the yelk, a small gran- 
ular mass of a rounded form is ex- 
truded from the yelk into the clear space 
beneath the zona pellucida. At a later 
period another similar mass is extruded. 
These are the polar globules (Fig. 46), and 
it is thought from observations on the 
invertebrata that they arise from the 
germinal vesicle, the remains of which 
gives origin to a new nucleus, which 
is known as the female pro-nucleus. 
These changes occur in all ovules, 
whether they are impregnated or not, 
but if the ovule is not fecundated, no 
further alterations occur. Supposing impregnation has taken place 
by the entrance of a spermatozoon within the zona pellucida of the 
ovule, a second nucleus is formed by the penetration of a spermatozoon 
within the yelk, where it loses its tail and becomes transformed into 
a granular body, the male pro-nucleus. After a time the male and 
female pro-nuclei approach one another and finally fuse to form a new 
nucleus, and the ovum then receives the name of the Blastosphere. or 
first segmentation sphere. 

After this occurs the very peculiar phenomenon known as the 
cleavage of the yelk, which results in the formation of the layer of 
cells from which the foetus is developed. The segmentation of the 
yelk (Fig. 47) occupies in mammals the whole of its substance. In 
birds the cleavage is confined to a small area of the yelk called the 
cicatricula or blastoderm. Hence the term Holoblastic has been applied 
to the ova of mammals, Meroblastic to those of birds. It divides at 
first into two halves, and at the same time the new or first segmenta- 
tion nucleus becomes constricted in its centre, and separates into two 
portions, one of which forms a centre for each of the halves into which 
the yelk has divided. Each of these immediately divides into two, as 
does its contained portion of the nucleus, and so on in rapid succession 
until the whole yelk is divided into a number of divisions, each of 
which consists of a clump of nucleated protoplasm. 

By these continuous dichotomous divisions the whole yelk is formed 
into a granular mass, which, from its supposed resemblance to a mul- 



Formation of the "polar globule." 
1. Zona pellucida, containing sperma- 
tozoa. 2. Yelk 3 and 4. Germinal 
vesicle. 5. The polar globule. 



CONCEPTION AND GENERATION 



101 



berry, has been named the muriform body. When the subdivision of 
the yelk is completed, its separate parts become converted into a num- 
ber of cells, each of which consists of a mass of granular protoplasm. 
Those evils unite by their edges to form a continuous lining ( Fig. 18), 
which, through the expansion of the muriform body by fluid which 
forms in its interior, is distended until it forms a Lining to the zona 
pellucida. This is the blastodermic membrane, from which the foetus 
is developed. By this time the ovum has reached the uterus, and, 



Fig. 47. 




Sections of the ovum of the rabbit during the later stages of segmentation, showing the formation 
ofthe blastodermic vesicle, a. Section showing the enclosure of entomeres, aiL, by ectomeres, eel, 
except at one spnt-the blastopore, b. More advanced stage, in which fluid is beginning to 
accumulate between the entomeres and ectomeres, the former completely encl< sed. c. The fluid has 
much increased, so that a large space separates entomeres from ectomeres. except at one part. 
d Blastodermic vesicle, its wall formed of a layer of ectodermic cells, with a patch of entomeres 
adhering to it at one part, z.p., ect, ent. As before. (After E. v. Beneden.) 

before proceeding to consider the further changes which it undergoes, 
it will be well to study the alteration which the stimulus of impregna- 
tion has set on foot in" the mucous membrane of the uterus, in order to 
prepare it for the reception and growth of its contents. 

Even before the ovum reaches the uterus, the mucous membrane 
becomes thickened and vascular, so that its opposing surfaces entirely 
fill the uterine cavity. These changes may be said to be the same id 
kind, although more marked and extensive in degree, as the alterations 



102 



PREGNANCY. 



which take place in the mucous membrane in connection with each 
menstrual period. The result is the formation of a distinct membrane, 
which affords the ovum a safe anchorage and protection, until its con- 
nections with the uterus are more fully developed. After delivery, 
this membrane, which is by that time quite altered in appearance, is 
at least partially thrown off with the ovum ; on which account it has 
received the name of the decidua or caduca. 



Fig. 48. 







Formation of the blastodermic membrane from the cells of the muriform body. 1. Layer of 
albuminous material surrounding 2. The zona peliucida. (After Joulin.) 



The decidua consists of two principal portions, which, in early 
pregnancy, are separated from each other by a considerable interspace, 
which is occupied by mucus. One of these, called the decidua vera, 
lines the entire uterine cavity, and is, no doubt, the original mucous 
lining of the uterus greatly hypertrophied. The second, the decidua 
reflexa, is closely applied round the ovum ; and it is probably formed 
by the sprouting of the decidua vera around the ovum at the point on 
which the latter rests, so that it eventually completely surrounds it. 
As the ovum enlarges, the decidua reflexa is necessarily stretched, 
until it comes everywhere into contact with the decidua vera, with 
which it firmly unites. After the third month of pregnancy true 
union has occurred, and the two layers of decidua are no longer 
separate. The decidua serotina, which is described as a third portion, 
is merely that part of the decidua vera on which the ovum rests, and 
where the placenta is eventually developed ; it is characterized by its 
extreme vascularity, Avhich serves the purpose of supplying nutriment 
to the foetus through the capillaries of the foetal placenta. 

It is needless to refer at length to the various views which have 
been held by anatomists as to the structure and formation of the de- 
cidua. That taught by John Hunter was long believed to be correct, 
and down to a recent date it received the adherence of most physiolo- 



CONCEPTION AND GENERATION. 103 

gists. lie believed the decidua to be an Inflammatory exudation 
which, on account of the Stimulus of pregnancy, was thrown out all 
over the cavity of the uterus, and soon formed a distinct lining mem- 
brane to it. When the ovum readied the uterine orifice of the Fal- 
lopian tube it found its entrance barred by this new membrane, which 
accordingly it pushed before it. This separated portion formed a 
covering to the ovum, and became the decidua reflexa, while a fresh 
exudation took place at that portion of the uterine wall which was 
thus laid bare, and this became the decidua serotina. William Hunter 
had much more correct views of the decidua, the accuracy of which 
was at the time much contested, but which have recently received full 
recognition. He describes the decidua in his earlier writings as an 
hypertrophy of the uterine mucous membrane itself, a view which is 
now held by all physiologists. 

AVheu the decidua is first formed it is a hollow triangular sac lining 
the uterine cavity (Fig. 49), and having three openings into it those 

Fig. 49. 




Aborted ovum of about forty days, showing the triangular shape of the decidua (which is 
laid open), and the aperture of the Fallopian tube. (After Coste.) 

of the Fallopian tubes at its upper angles, and one, corresponding^ to 
the internal os uteri, below. If, as is generally the case, it is thick 
and pulpy, these openings are closed up, and can no longer be detected. 
In early pregnancy it is well developed, and continues to grow up to 
the third month of utero-gestation. After that time it commences to 
atrophy, its adhesion with the uterine walls lessens, it becomes thin 
and transparent, and is ready for expulsion when delivery i> effected. 
When it is most developed, a careful examination of the decidua 
enables us to detect in it all the elements of the uterine mucous mem- 
brane greatly hypertrophied. Its substance chiefly consists of large 



104 



PREGNANCY 



round or oval nucleated cells and elongated fibres, mixed with the 
tubular uterine glands, which are much elongated, lined by columnar 
ciliated epithelial cells, and contain a small quantity of milky fluid. 
According to Friedlander, the decidua is divisible into two layers : 
the inner being formed by a proliferation of the corpuscles of the sub- 
epithelial connective tissue of the mucous membrane ; the deeper, in 
contact with the uterine Avails, out of flattened or compressed gland 
ducts. In an early abortion the extremities of these ducts may be 
observed by a lens on the external or uterine surface of the decidua, 
occupying the summit of minute projections, separated from each other 
by depressions. If these projections be bisected they will be found to 
contain little cavities, filled with lactescent fluid, which were first 
described by Montgomery, of Dublin, and are known as Montgomery's 
cups. They are in fact the dilated canals of the uterine tubular 
glands. On the internal surface of such an early decidua a number 
of shallow depressions may be made out, which are the open mouths 
of these ducts. 



Fig. 50. 



Fig. 51. 



Fig. 52. 






Formation of decidua. (The 
decidua is colored black, 
the ovum is represented as 
engaged between two project- 
ing folds of membrane.) 



Projecting folds of membrane 
growing up around the ovum. 
(After D alton.) 



Showing ovum completely 
surrounded by the decidua 

reflesa. 



The decidua vera is highly vascular, and its vascularity persists till 
after the seventh month of pregnancy ; the decidua reflexa is only 
vascular during the early part of pregnancy, depending for its vas- 
cularity chiefly on the villi of the chorion, and hence losing this Avith 
their atrophy. 

When the ovum reaches the uterine cavity it soon becomes imbedded 
in the folds of the hypertrophied mucous membrane, which almost 
entirely fills the uterine caA'ity. As a rule it is attached to some point 
near the opening of a Fallopian tube, the swollen folds of mucous 
membrane preventing its descent to the lower part of the uterus ; in 
exceptional circumstances, howeA T er — as in women who have borne 
many children, and haA^e a more than usually dilated uterine caA'itv — 
it may fix itself at a point much nearer the internal os uteri. Accord- 
ing to the now generally accepted opinion of Coste, the mucous mem- 
brane at the base of the ovum soon begins to sprout around it, and 



CONCEPTION' AND GENERATION. LOS 

gradually extends until it eventually covers the ovum (Figs, 50-52), 
and forms the decidua reflexa. Coste describes, under the name of 
tlu- umbilicus, a small depression at the mosl prominent pari of the 
ovum, which he considers to be the indication of the |><>int where the 
closure of the decidua reflexa is effected. There are some objections 
to this theory, for uo one has Been the decidua reflexa incomplete and 
in the process of formation, and on examining it- external surface, 
that is, the one farthest from the ovum, it- microscopical appearance 
is identical with that of the inner surface of the decidua vera. To 
meet these difficulties, Weber and Goodsir, whose views have been 
adopted by Priestley, contended that the decidua reflexa i- "the 
primary lamina of the mucous membrane, which, when the ovum 
enters the uterus, separates in two-third- of it- extent from the layer- 
beneath it to adhere to the ovum; the remaining third remain- at- 
tached, and forms a centre of nutrition.'' According to this view the 
decidua vera would be a subsequent growth over the separated por- 
tion, and the decidua serotina the portion of the primary lamina which 
remained attached. In this way the fact of the opposed surfaces of 
the decidua vera and reflexa being identical in structure would he 
accounted for. The difficulty which this theory is intended to meet 
does not seem so great as is supposed, for if, as is likely, it is only the 
epithelial or internal surface of the mucous membrane which sprouts 
over the ovum, and not its deeper layers, the facts of the case would 
be sufficiently met by Coste's view. 

Fig. 53. 




\n ovum removed from uterus, and part of the decidua vera cut away. a. Decidua 
showing the follicles opening on its inner surface, b. Inner extremity of Fallopian tube. 
c. Flap of decidua reflexa. d. Ovum. 'After Costs.] 



vera 



Up to the third month of pregnancy the decidua reflexa and 
are not inclose contact, and there may even be a considerable inter- 
space between them, which sometimes contains a -mall quantity of 
mucous fluid, called the hydrojk , This fact may account for the 

curious circumstance, of which many instances are on record, that a 



106 PREGNANCY. 

uterine sound may be passed into a gravid uterus in the early months 
of pregnancy without necessarily producing abortion, and also for the 
occasional occurrence of menstruation after conception (Figs. 53 and 
£1). Eventually, by the growth of the ovum, the decidua reflexa 
comes closely into contact with the vera, and the two become intimately 
blended and inseparable. The inner surface of the decidua reflexa 
blends with the outer surface of the chorion, so that at birth the decidua 
vera, the decidua reflexa, and the chorion are represented by one mem- 
brane. 

As pregnancy advances the decidua alters in appearance and becomes 
fibrous and thin. In the later months of utero-gestation fatty degenera- 
tion of its structure commences, its vessels and glands are obliterated, 
and its adhesion to the uterine walls is lessened, so as to prepare it for 
separation. As we shall subsequently see, this fatty degeneration was 
assumed by Simpson to be the determining cause of labor at term. 
After the eighth month, thrombi form in the veins lying underneath 
the decidua serotina, and at the end of pregnancy they are described 
by Leopold 1 as having become, to a great extent, obliterated. This, 
he supposes, may have some effect in inducing the contractions of the 
uterus in labor. 

It was long believed that the entire decidua was thrown off after 
labor, leaving the muscular coat of the uterus bare and denuded, and 
that a new mucous membrane was formed during convalescence. Ac- 
cording to Robin, 2 whose views are corroborated by Priestley, no such 
denudation of the muscular tissue of the uterus ever occurs, but a por- 
tion of the decidua always remains attached after delivery. After the 
fourth month of pregnancy, they believe, a new mucous membrane 
is formed under the decidua, which remains in a somewhat imperfect 
condition till after delivery, when it rapidly develops and assumes the 
proper functions of the mucous lining of the uterus. Robin also be- 
lieves that that portion of the decidua which covers the placental site, 
the so-called decidua serotina, is not thrown off with the membranes, 
like the decidua vera and reflexa, but remains attached to the uterine 
walls, a thin layer of it only being expelled with the placenta, on which 
it may be observed. Duncan 3 entirely dissents from these views, and 
does not admit the formation of a new mucous membrane during the 
later months of utero-gestation. He believes that the greater portion 
of the decidua is thrown off, but that part remains, and from this the 
fresh mucous membrane is developed. This view is similar to that of 
Spiegelberg, who holds that the portion of the decidua that is expelled 
is the more superficial of the two layers described by Friedlander, com- 
posed chiefly of the epithelial elements, while the deeper or glandular 
layer remains attached to the walls of the uterus. From the epithelium 
of the glands a new epithelial layer is rapidly developed after delivery. 
Leopold 4 has shown that the uterine mucous membrane is completely 
re-formed within six weeks after delivery, and that its regeneration is 

1 Arch. f. Gyn., 1S77, Bd. xi., Heft 3, S. 443. "Studien liber die Uterus-schleimhaut wahrend 
Menstruation." 

2 Memoires del' Acad. Imp. de Med., 1861. 

3 Researches in Obstetrics, p. 186 et seq. 

4 Arch. f. Gyn., 1S77, Bd. xii., Heft 2, S. 169. 



CONCETTI ON AND GENERATION. 107 

sometimes completed as early as the end of the third week. This 
theory bears on the well-known analogy of the uterus after delivery 
to the stump of an amputated limb, an old simile, principally based 
on the erroneous theory thai the whole muscular tissue or the uterus 
was laid hare. This, as we have Been, Is not the case, bul the simile so 
tar holds good in that the mucous lining is deprived of its epithelial 
covering; and this fact, together with the existence of numerous open 
veins on the interior of the uterus, readily explains the extreme sus- 
ceptibility to septie absorption, which forms so peculiar a characteristic 
of the puerperal state. 

Before we commenced the study of the decidua we had traced the 
impregnated ovum into the uterine cavity, and described the formation 
of the blastodermic membrane by the junction of the cells of the mnri- 
form body. AVe must now proceed to consider the further changes 
which result in the development of the foetus, and of the membranes 
that surround it. It would be quite out of place in a work of this 
kind to enter into the subject of embryology at any length, and we 
must therefore be content with such details as are of importance from 
a practical point of view. 

The blastodermic membrane, which forms a complete spherical lining 
to the ovum, between the yelk and the zona pellucida, soon divides 
into two layers, of which the external is called the epiblast, the internal 
the hypoblast, and between these is subsequently developed a third layer, 
known as the mesoblast. From these three layers are formed the entire 
foetus: the epiblast giving origin to the central nervous system, to the 
superficial layer of the skin, and aiding in formation of the organs of 
special sense, and of the amnion; the hypoblast forming the epithelial 
lining membrane of the alimentary and respiratory tracts, and of the 
tubes and glands in connection with them, and helping in the develop- 
ment of the yelk sac; the mesoblast giving rise to the skeleton, the 
muscles, the connective tissues, the vascular system, the genito-urinary 
organs, and taking part in the formation of all the membranes. 

Almost immediately after the separation of the blastodermic mem- 
brane into layers, one part of it becomes thickened by the aggregation 
of cells, and is called the area germinativa. This is at first round and 
then oval in shape, and at its margin the first indication of the embryo 
may be detected in the form of a narrow thickening, the primitive trace. 
This becomes elongated, and stretches in a strap-like form along the 
centre of the germinal area ; it is considered by Balfour to represent 
the Blastopore of animals, the ova of which undergo invagination to 
form a Gastrula. Surrounding it are some cells more translucent than 
those of the rest of the area germinativa, and hence called the area 
pellucida (Fig. 54). In front of the primitive trace two elevated ridges 
soon arise, the lamince dorsales, which include between them a groove, 
the medullary groove, and gradually unite posteriorly to form a cavity 
within which the cerebro-spinal axis i- subsequently developed. The 
medullarv groove as it grows backward overlaps the primitive trace, 
which disappears. The embryo is differentiated from the rest of the 
blastoderm by a fold anteriorly, which i> called the cephalic or head 
fold. Another fold afterward appears posteriorly, which is called the 



108 



PKEGNANCY. 



caudal or tail fold. Laterally, folds also arise. These folds all tend 
to grow toward the centre of the under surface of what will be the 
embryo. 

The mesoblastic layer of the blastoderm, except that part which 
forms the axis of the embryo, splits into an upper layer, the somato- 
pleure, which is beneath the epiblast, and a lower layer, the splanchno- 
pleure, which lies upon the hypoblast. The space formed by this 
cleavage of the mesoblast is called the pleuro-peritoneal cavity. The 
somato-pleure is engaged in the formation of the body walls of the 
embryo. The splanchno-pleure forms the walls of the alimentary 
tract. 




Diagram of area germinativa, showing the primitive trace and area pellucida. 



Formation of the Amnion. — Processes arise from the somato- 
pleure anteriorly, posteriorly, and laterally, which gradually arch over 
the dorsal surface of the foetus, until they meet each other and form a 
complete envelope to it. At the ventral surface these processes are 
separated by the whole length of the embryo, but they here also gradu- 
ally approach each other, and eventually surround what is subsequently 
the umbilical cord, and blend with the integument of the foetus at the 
point of its insertion. In this way is formed the amnion (Fig. 55), 
consisting of two layers: the internal, derived from the epiblast, is 
formed of tessellated epithelial cells ; the external, arising from the 
mesoblast, is formed of cells like those of young connective tissue. 
Before the folds of the amnion unite, the free edge of each is bent out- 
ward and spreads around the ovum, immediately within the zona 
pellucida, forming a lining to it, termed by Turner the sub-zonal mem- 
brane, which is connected with the development of the chorion. In 
man this reflected layer, or false amnion, consists only of epiblast, but 
in some other animals it is probably formed from both the mesoblast 
and the epiblast, like the true amnion. The amnion is the most in- 
ternal of the membranes surrounding the foetus, and will presently be 
studied more in detail. It soon becomes distended with fluid, the 
liquor amnii, and as this increases in amount it separates the amnion 
more and more from the foetus. 

During this time the innermost layer of the blastodermic membrane 



CONCEPTION AND GENERATION, 



109 



or hypoblasl is also developing two projections at either extremity of 
the foetus, and these gradually approach cadi other anteriorly, la 
the hypoblast is in contact with the yelk, when these meel they have 



Fig 55. 



' 



JteScS^ 




Development of the amnion. 1. Vitelline 
membrane. 2. External layer of blastodermic 
membrane. 3. Internal layers forming the 
umbilical vesicle. 4. Umbilical vessels. 5. 
Projections forming amnion. 6. Embryo. 
7. Allantois. 




1. Exochorion. 2. External layer of blasto- 
dermic membrane. 3. Umbilical vesicle. 4. Its 
vessels. 5. Amnion. 6. Embryo. 7. Allantois 
increasing in size. 



the effect of dividing the yelk into two portions. One, and the 
smaller of the two, forms eventually the intestinal canal of the fetus ; 
the other, and much the larger, contains the greater portion of the 



Fig. 57. 



Fig. 58. 




An embryo of about twenty-five 
days laid open. a. Chorion, b. Am- 
nion, c. Cavity of chorion, d. Um- 
bilical vesicle, e. Pedicle of allan- 
tois. /. Embryo. (After Coste.j 




1. Exochorion. 2. External layer of the blasr.v 
dermic membrane. 3. Allantois. 4. Umbilical vesicle. 
5. Amnion. G. Embrvo. 7. Pedicle of allantois. 



yelk, and forms the ephemeral structure known as the umbilical vesicUj 
from which the foetus derive- most of its nourishment during the 
early stage of its existence. Its communication with the abdominal 



110 PREGNANCY. 

cavity of the foetus is through the constricted portion at the point of 
division called the vitelline duct (Fig. 56). An artery and vein, the 
omphalo-mesenteinc, ramify on the vesicle and its duct. 

As the amnion increases in size, it pushes back the umbilical vesicle 
toward the external membrane of the ovum, between which and the 
amnion it lies (Fig. 57) ; and when the allantois is developed, it ceases 
to be of any use, and rapidly shrinks and dwindles away. In most 
mammals no trace of it can be found after the fourth month of utero- 
gestation ; in some, including the human female, it is said to exist as a 
minute vesicle at the placental end of the umbilical cord at the full 
period of pregnancy. The umbilical vesicle is filled with a yellowish 
fluid, containing many oil and fat globules, similar to the yelk of an 

egg- 

The Allantois. — Somewhere about the twentieth day after concep- 
tion a small vesicle is formed toward the caudal extremity of the 
foetus, which is called the allantois. This membrane in mammals is 
important, as it forms the greater part of the foetal placenta, a small 
portion of it remaining inside the body permanently as the bladder. 
It begins as a diverticulum from the lower part of the intestinal canal, 
and is hence formed externally by the splanchno-pleural layer of the 
mesoblast, whilst internally it is lined by the hypoblast. It is at first 
spherical, but it rapidly develops and becomes pyriform in shape, 
while by a process of constriction, similar to that which occurs in the 
vitellus to form the umbilical vesicle, it becomes divided into two 
parts, communicating with each other, the smaller of them being 
eventually developed into the urinary bladder. The larger portion, 
leaving the abdominal cavity along with the vitelline duct, rapidly 
grows until it comes into contact with the most external ovular mem- 
brane, the chorion, over the inner surface of which it spreads. This 
part consists chiefly of mesoblastic tissue, the hypoblast only passing 
to the end of the stalk of the allantois, and not following the mesoblast 
as it spreads over the inner surface of the chorion. The area of the 
chorion over which the allantois spreads varies in different animals ; 
in man it spreads over the entire surface, but in the rabbit it only 
occupies one-third of the chorion, the remaining two-thirds being 
occupied by the yelk sac. This varying distribution of the allantois 
helps to differentiate the placentation of man and the apes from that 
of rodents. In the mesoblastic tissue of the allantois, vessels soon 
develop ; namely, the two umbilical arteries, derived from the abdom- 
inal aorta, and two umbilical veins, one of which subsequently dis- 
appears ; these, along with the vitelline duct and the pedicle of the 
allantois, form the umbilical cord. The main and very important 
function of the allantois, therefore, is to carry the foetal vessels up to 
the inner surface of the sub-zonal membrane. Besides this purpose, 
the allantois, at a very early period, may receive the excretions of the 
foetus, and serve as an excrementitious organ. According to Cazeaux, 
scarcely a trace of the allantois can be seen a few days after its forma- 
tion. Its lower part or pedicle, however, long remains distinct, and 
forms part of the umbilical cord ; and traces of it may be found even 
in adult life in the form of the urachus, which is really the dwindled 



CONCEPTION AND GENERATION 



111 



pedicle, and forms one of the ligaments of the bladder. The cavity 
of the allantois in the human species is confined chiefly to thai part 
which lies within the body of the foetus; ii is seldom pereistenl further 

than the stalk of the allantois. 



Pig. 59. 




Five diagrammatic figures illustrating the formation of the foetal membranes of a mammal. In 
1, 2, 3, 4, the embryo is represented in longitudinal section. 1. Ovum with zona pellucida, blasto- 
dermic vesicle, and embryonic area ; 2. Ovum with commencing formation of umbilical vesicle 
and amnion ; 3. Ovum with amnion about to cease, and commencing allantois ; 4. Ovum with 
villous sub-zonal membrane, larger allantois, and mouth and anus ; 5. Ovum In which the meso- 
blast of the allantois has extended round the inner surfaceof the sub-zonal membrane and united 
with it to form the chorion. The cavity of the allantois is aborted. This figure is a diagram of an 
early human ovum. d. zona radiata ; d' and sz. processes of zona; sh. sub-zonal membrane, outer 
fold of amnion, false amnion; ch. chorion; ch.z. chorionic villi ; am. amnion ; J:s. head fold of 
amnion ; ss. tail fold of amnion ; a. epiblast of embryo ; a', epiblast of non-embryonic part of the 
blastodermic vesicle : m. embryonic mesoblast ; m'. non-embryonic mesoblast ; df. area vasculosa ; 
st. sinus terminalis : dd. embryonic hypoblast ; i. non-embryonic hypoblast ; kh. cavity of blasto- 
dermic vesicle, the greater part of which becomes the cavity of umbilical vesicle d$. : dg. stalk of 
umbilical vesicle ; al. allantois; e. embryo; r. space between chorion and amnion containing 
albuminous fluid ; vl. ventral body wall ; hh. pericardial cavity. (After K<>u.iki.u.) 



112 PKEGNANCY. 

Between the chorion and amnion is often fonnd an albuminous fluid, 
with minute filamentous processes traversing it, called by Velpeau the 
corps reticule, which is not met with until the allantois comes into 
contact with the chorion, and which seems to be formed out of the 
tissues of that vesicle. It is analogous to the so-called Wharton's 
jelly found in the umbilical cord. When first formed it is highly 
vascular, but the vessels entirely disappear after the placenta is formed, 
and the remainder of the chorionic villi atrophy. Sometimes it exists 
in considerable quantities, and, should the chorion rupture at the end 
of pregnancy, it may escape and give rise to an erroneous impression 
that the liquor amnii has been discharged. (Fig. 59.) 

Before proceeding to consider the foetal envelopes more at length, it 
may be useful to recapitulate the structures already alluded to as form- 
ing the ovum. In this we find : 

1. The embryo itself. 

2. A fluid, the liquor amnii, in which it floats. 

3. The amnion, a purely foetal membrane surrounding the embryo, 
and containing the liquor amnii. 

4. The umbilical vesicle, containing the greater portion of the yelk, 
serving as a source of nutrition to the early embryo through the vitel- 
line duct, and on which ramify the omphalo-mesenteric vessels. 

5. The allantois, a vesicle proceeding from the caudal extremity of 
the embryo, spreading itself over the interior of the ovum, and serving 
as a channel of vascular communication between the chorion and the 
foetus, through the umbilical vessels. 

6. An interspace between the outer layer of the ovum and the 
amnion, in which is contained the umbilical vesicle and allantois, and 
the corps reticule of Velpeau. 

7. The outer layer of the ovum, along with the sub-zonal membrane, 
forming the chorion and foetal placenta. 

The amnion is the most internal of the two membranes surround- 
ing the foetus ; its origin at an early period of foetal life has already 
been described. It is a perfectly smooth, transparent, but tough mem- 
brane, continuous with the integument of the foetus at the insertion of 
the umbilical cord, round which it forms a sheath. Soon after it is 
formed it becomes distended with a fluid, the liquor amnii, in which 
the foetus is suspended and floats. This fluid increases gradually in 
quantity, distending the amnion as it does so, until this is brought into 
close proximity to the inner surface of the chorion, from which it was 
at first separated by a considerable interspace. 

The internal surface of the amnion is smooth and glistening, and 
on microscopic examination it is found to consist of a layer of flattened 
cells, each containing a large nucleus. These rest on a stratum of 
fibrous tissue, which gives to the membrane its toughness, and by 
which it is attached to a layer of gelatinous tissue which separates it 
from the inner surface of the chorion. This fibrous layer contains 
muscular fibres which give to the amnion its contractility. It is 
entirely destitute of vessels, nerves, and lymphatics. The quantity 
of the' liquor amnii varies much at different periods of pregnancy. 
In the early months it is relatively greater in amount than the foetus, 



CONCEPTION AND GENERATION. 1 1 3 

which it outweighs. As pregnancy advances, the weight of the foetus 
becomes tour or five times greater than that of the liquor amnii, 
although the actual quantity of fluid increases during the whole 

period of gestation. The amount of fluid varies much in different 
pregnancies. Sometimes there is comparatively little; while at others 
the quantity is immense, reaching several pounds in weight, great I v 
distending the uterus, and thus, it may be, producing difficulty in 
labor. 

At first the liquid is clear and limpid. As pregnancy advances it 
becomes more turbid and dense, from the admixture of epithelial 
debris derived from the cutaneous surface of the foetus. In some 
cases, without actual disease, it may be dark-green in color, and thick 
and tenacious in consistency. It has a peculiar heavy odor, and it 
consists chemically of water containing albumin, some urea, and 
various salts, principally phosphates and chlorides. 

The source of the liquor amnii has been much disputed. Some 
maintain that it is derived chiefly from the fetus, a view sufficiently 
disproved by the fact that the liquor amnii continues to increase in 
-amount after the death of the foetus. Burdach believed that it is 
secreted by the internal surface of the uterus, and arrives in the 
cavity of the amnion by transudation through the membrane. Priest- 
ley thinks — and this seems the most probable hypothesis — that it is 
secreted by the epithelial cells lining the membrane, which become 
distended with fluid, burst, and pour their contents into the amniotic 
cavity. Gusserow, 1 whose view is adopted by Spiegelberg, maintains 
that in the latter months of pregnancy the quantity of the liquor 
amnii is largely increased by the foetal urine which is passed into the 
amniotic sac. (See page 137.) 

The most obvious use of the liquor amnii is to afford a fluid medium 
in which the foetus floats, and so is protected from the shocks and jars 
to which it would otherwise be subjected, and from undue pressure 
upon the uterine walls. By distending the uterus it saves it from 
injury, which the movements of the foetus might otherwise inflict, and 
the foetus is thus also enabled to change its position freely. The 
facility with which version by external manipulation can be effected 
depends entirely on the mobility of the foetus in the fluid which sur- 
rounds it. Some have also supposed that it prevents the foetus, in 
the early months of pregnancy, from forming adhesions to the amnion. 
In labor, it is of great service, by lubricating the passages, but chiefly 
I>y forming, with the membranes, a fluid wedge, which dilates the 
circle of the os uteri. 

In a few rare cases there is a certain amount of limpid fluid between 
the chorion and the amnion, separating the two membranes. This is 
apparently only a more than usually fluid condition of the gelatinous 
tissue which naturally exists between the chorion and amnion. ( )cca- 
sionallv, after the bag of membranes is felt in labor, the chorion alone 
ruptures, and the spurious liquor amnii is discharged, giving the 
attendant the impression that the membranes have been ruptured. 

i Arch. f. Ciyuiik., Bd. iii. S. 241, " Zur Lehre vom Stoffwechsel des Foetus " 

8 



114 PREGNANCY. 

The chorion is the more external of the truly foetal membranes, 
although external to it is the decidua, having a strictly maternal 
origin. It is a perfectly closed sac, its exterual surface, in contact 
with the decidua, being rough and shaggy from the development of 
villi (Fig. oQ), its internal smooth and shining. As the ovum passes 
along the Fallopian tube it receives, as we have seen, an albuminous 
coating, and this, with the zona pellucida, is developed into a tem- 
porary structure, the primitive chorion. This primitive chorion, as 
the amnion develops, is reinforced by the layer of epiblast covering 
the umbilical vesicle externally which separates it from the subjacent 
mesoblast and hypoblast, and together with the epiblastic layer of the 
false amnion, with which it is continuous, passes to the primitive 
chorion, either combining with this, or by pressure causing its absorp- 
tion and disappearance. 

The membrane thus formed is called by Turner the sub-zonal mem- 
brane, and by Von Baer the serous envelope. From it are developed 
villi of cellular structure, which at first extend as a ring round the 
ovum, but eventually cover the whole of its surface. These villi are 
finger-like projections from the surface of the ovum, which are re- 
ceived into corresponding depressions in the decidua, with which they 
soon become so firmly united that they cannot be separated without 
laceration. 

As the allantois develops, its mesoblastic layer grows into the space 
between the embryo and the sub-zonal membrane, and, in the human 
subject, spreads over the whole of its inner surface, combining with it 
to form a new membrane, the true or complete chorion. Each villus 
now receives a separate artery and vein, the former having a branch 
to each of the subdivisions into which the villus divides. These 
vessels are encased in a fine connective-tissue sheath from the allantois, 
which enters the villus along with them and forms a lining to it 
described by some as the endochorion ; the external epithelial mem- 
brane of the villus, derived from the epiblast layer of the blastodermic 
membrane, being called the exochorion. The artery and vein lie side 
by side in the centre of the villus, and anastomose at its extremity ; 
each villus thus having a separate circulation. 

As soon as the union of the allantois with the chorion has been 
effected, the villi grow very rapidly, give off branches, which, in their 
turn, give off secondary branches, and so form root-like processes of 
great complexity. In the early months of gestation they exist equally 
over the whole surface of the ovum. As pregnancy advances, how- 
ever, those which are in contact with the decidua reflexa shrivel up, 
and by the end of the second month cease to be vascular, being no 
longer required for the nutrition of the ovum. The chorion and 
decidua thus come into close contact, being united together by fibrous 
shreds, which on microscopic examination are found to consist of 
atrophied villi. The union between the chorion and the decidua re- 
flexa as pregnancy advances becomes so complete that their line of 
junction cannot be ascertained, and they together with the decidua 
vera form one membrane, which on its inner surface is only separated 
from the amnion, which has spread over it, by a fine layer of gelatinous 



CONCEPTION AND GENERATION. 115 

tissue. The portion of the chorion which is in relationship to the 
decidua reflexa is known as the chorion lame, whilst thai in contact 
with the decidua serotina receives the name of the chorion frondasum, 
and in this portion the villi, instead of dwindling away, increase 
greatly in size, and eventually develop into the organ by which the 
foetus is nourished — the placenta. 

Form of the Placenta. — This important organ serves the purpose 
of supplying nutriment to, and aerating the blood of, the foetus, and on 
its integrity the existence of the foetus depends. It is met with in all 
mammals, but is very different in form and arrangement in different 
classes. Thus, in the sow, mare, and in the cetacea, it is diffused over 
the whole interior of the uterus; in the ruminants, it is divided into a 
number of separate small masses, scattered here and there over the 
uterine walls ; while in the carnivora and elephant it forms a zone or 
belt round the uterine cavity. In the human race, as well as in 
rodentia, inseetivora, etc., the placenta is in the form of a circular 
mass, attached generally to some part of the uterus near the orifice of 
one Fallopian tube; but it may be situated anywhere in the uterine 
cavity, even over the internal os uteri. The form of placcntation in 
man and the apes is knoAvn as the meta-discoidal, whilst in rodentia 
and inseetivora the placentation is discoidal. The meta-discoidal 
placentation is placed ventrally with regard to the embryo, and the 
allantois extends over the whole of the sub-zonal membrane, whilst in 
the discoidal variety the placenta is placed dorsally, and the allantois 
only extends over a portion of the sub-zonal membrane, to the re- 
mainder of which the yelk sac is applied. As it is expelled after 
delivery with the foetal membranes attached to it, and as the aperture 
in these corresponds to the os uteri, we can generally determine pretty 
accurately the situation in which the placenta was placed by examining 
them after expulsion. The maternal surface of the placenta is some- 
what convex, the foetal concave. Its size varies greatly in different 
cases, and it is usually largest when the child is big, but not necessarily 
so. Its average diameter is from six to eight inches, its weight from 
eighteen to twenty-four ounces, but in exceptional cases it has been 
found to weigh several pounds. Abnormalities of form are not very 
rare. Thus, the placenta has been found to be divided into distinct 
parts, a form said by Professor Turner to be normal in certain genera 
of monkevs; or smaller supplementary placentae (placentce suceenti/i-i" ) 
may exist round a central mass. These variations of shape arc only 
of importance in consequence of a risk of part of the detached placenta 
being left in the uterus after delivery, and giving rise to septicaemia 
or secondary hemorrhage. 

The foetal membranes cover the whole foetal surface of the placenta, 
being reflected from its edges so as to line the uterine cavity, and being 
expelled with it after delivery. They also leave it at the insertion of 
the cord, to which they form a sheath. The cord is generally attached 
near the centre of the placenta, and from its insertion the umbilical 
vessels may be seen dividing and radiating over the whole foetal 
surface. 

The maternal surface i- rough and divided by numerous sulci, which 



116 



PREGNANCY. 



are best seen if the placenta is rendered convex, so as to resemble its 
condition when attached to the uterus. A careful examination shows 
that a delicate membrane covers the entire maternal surface, unites the 
sulci together, and dips down between them. This is, in fact, the 
cellular layer of the decidua serotina, which is separated and expelled 
with the placenta, the deeper layer remaining attached to the uterus. 
Numerous small openings may be seen on the surface, which are the 
apertures of the veins torn off from the uterus, as also those of some 
arteries, which, after taking several sharp turns, open suddenly into 
the substance of the organ. 

As regards the minute structure of the placenta, it is certain that it 
cousists essentially of two distinct portions — one foetal, consisting of 

Fig. 60. 




Placental villus, greatly magnified. 1, 2. Placental vessels, forming terminal loops. 3. Chorion 
tissue, forming external walls of villus. 4. Tissue surrounding vessels. (After Joulin.) 

the greatly hypertrophied chorion villi, with their contained vessels, 
■which carry the foetal blood so as to bring it into intimate relation with 
the maternal blood, and thus admit of the necessary changes occurring 
in it connected with the nutrition of the foetus ; and the other maternal, 
formed out of the decidua serotina and the maternal bloodvessels. 
These two portions are in the human female so intimately blended 
as to form the single deciduous organ which is thrown off after 
delivery. These main facts are admitted by all, but considerable 
differences of opinion still exist among anatomists as to the precise 
arrangement of these parts. In the following sketch of the subject I 
shall describe the views most generally entertained, merely briefly 
indicating the points which are contested by various authorities. 



CONCEPTION' AND GENERATION 



III 



The foetal portion of the placenta consists essentially of the ultimate 
ramifications of the chorion villi, which may be Been on microscopic 
examination in the fom of club-shaped dictations, which are given 
off at every possible angle from the stem or a parent trunk,jus1 like 
the branches of a plant. Within the transparent walls of the villi the 
capillary tubes of the contained vessels may be seen lying, distended 
with Mood, and presenting an appearance nol unlike loops of Bmall 
intestine. The capillaries are the terminal ramifications of the 
umbilical arteries and veins, which, after reaching the Bite of the 
placenta, divide and subdivide until they at last form an immense 
number of minute capillary vessels, with their convexities looking 
toward the maternal portion of the placenta, each terminal loop being 
contained in one of the digitations of the chorion villi. Each arterial 
twig is accompanied by a corresponding venous branch, which unites 
with it to form the terminal arch or loop (Fig. GO). The foetal blood 



Fig. 61. 




a. Terminal villus of fcetal tuft, minutely injected, b. Its nucleated non-vascular sheath. 

(After Farke.) 



is carried through these arterial twigs to the villi, where it comes into 
intimate contact with the maternal blood, in consequence of the 
anatomical arrangements presently to be described ; but the two do not 
directly mix, as the older physiologists believed, for none of the 
maternal blood escapes when the umbilical cord is cut, nor can the 
.minutest injections through the foetal vessels be made to pass into the 
maternal vascular system, or vice verso. In addition to the looped 
terminations of the umbilical vessels, Farre and Schroeder van der 
Kolk have described another set of capillary vessels in connection with 
each villus (Fig. 61). This consists of a very tine network covering 
each villus, and very different in appearance from the convoluted 
vessels lying in its interior, which are the only ones which have been 
usually described. Dr. Farre believes that these vessels only exist in 
the early months of pregnancy, and that they disappear as pregnancy 



118 PREGNANCY. 

advances. Priestley 1 suggests that they may not be vessels at all, but 
lymphatics, which may possibly absorb nutrient material from the 
mother's blood, and throw it into the foetal vascular system. The 
existence of lymphatics, or of nerves, in the placenta, however, has 
never been demonstrated, and they are believed not to exist. 

As generally described, the maternal portion of the placenta consists 
of large cavities, or of a single large cavity, which contain the maternal 
blood, and into which the villi of the chorion penetrate (Fig. 62). 
Into this maternal part of the viscus, the curling arteries of the uterus 
pour their blood, which is collected from it by the uterine sinuses. 

Fig. 62. 




c 

Diagram representing a vertical section of the placenta, a. a. Chorion, b, b. Decidua. 
c, c, c, c. Orifices of uterine sinuses. (After Dalton.) 

The villi of the chorion, therefore, are suspended in a sac filled with 
maternal blood, which penetrates freely between them, and with which 
they are brought into very intimate contact. Dr. John Reid believed 
that only the delicate internal lining of the maternal vessels entered 
the substance of the placenta, to form the sac just spoken of. Into 
this the villi project, pushing before them the membrane forming the 
limiting wall of the placental sinuses, each of them in this way re- 
ceiving an investment, just as the fingers of a hand are covered by a 
glove (Fig. 63). 

Schroeder van der Kolk and Goodsir (Fig. 64) w r ere of opinion 
that not only were the maternal bloodvessels continued into the sub- 
stance of the placenta, but also the processes of the decidua, which 
accompanied the vessels and were prolonged over each villus, so as to 
separate it from the lining membrane of the maternal sinuses. Each 
villus would thus be covered by two layers of fine tissue, one from the 
internal lining membrane of the maternal bloodvessels, the other from 
the epithelial cells of the decidua. 

1 The Gravid Uterus, p. 52. 



CONCEPTION' AND GENERATION. 



L19 



Turner, whose valuable researches on the comparative anatomy of 
the placenta have thrown much Light on its structure, points out that 
the placentae of all animals are formed on the same fundamental type, 1 
in which the foetal portion consists of a smooth, plane-surfaced vas- 
cular membrane, covered with pavement epithelium, which is brought 
into contact with the maternal portion, consisting of a smooth, plane- 
surfaced vascular membrane covered with columnar epithelium. The 
foetal capillaries are separated from the maternal capillaries only by 
two opposed layers of epithelium. In various animals the placentas 
are more or less specialized from the generalized form, in some to a 
much greater extent than others. In the human placenta the maternal 



Fig. 63. 



C— ~. 




Fig. 64. 




Diagram illustrating the mode in which a 
placental villus derives a covering from the 
vascular system of the mother, a. Villus 
having three terminal digitations projecting 
into b. Cavity of the mother' s vessel . c. Dotted 
lines representing coat of vessel. (After 
Priestley.) 



The extremity of a placental villus, a Ex- 
ternal membrane of villus (the lining mem- 
brane of vascular system of Weber), b. Ex- 
ternal cells of villus derived from decidua. 
c, c. Nuclei of ditto, d. The space between 
the maternal and foetal portions of villus. 
e. Its internal membrane. /. Its internal 
cells, g. The loop of umbilical vessels. 
(After Goodsir.) 



vessels have lost their normal cylindrical form, and are dilated into 
a system of freely intercommunicating placental sinuses, which are, in 
fact, maternal capillaries enormously enlarged, with their walls so 
expanded and thinned out that they cannot be recognized as a distinct 
layer limiting the sinus. Each foetal chorion villus projecting into 
these sinuses is covered with a layer of cells distinct from those of the 
epithelial layer of the villus, and readily stripped from it. These are 
maternal in their origin, and are derived from the decidua, which 
sends prolongations of its tissue into the placenta. These cells, he 
believes, form a secreting epithelium which separates from the maternal 
blood a secretion, for the nourishment of the foetus, which is, in its 
turn, absorbed by the villi of the chorion. 

A view not very dissimilar to this has been advanced by Professor 
Ercolani, of Bologna, who maintains that the maternal portion of the 
placenta is a new formation, strictly glandular, and not vascular, in 
its structure. It is formed, he thinks, by the submucous connective 
tissue of the decidua serotina, and it dips down into the placenta and 



i Introduction to Human Anatomy, Part 2, and Journ. of Anat. and 1'hysiology, 1877, vol. xi. 
p. 33. 



120 PREGNANCY. 

forms a sheath to each of the chorion villi, which it separates from 
the maternal blood. This new glandular structure he describes as 
secreting a fluid, termed the " uterine milk," which is absorbed by the 
villi of the chorion, just as the mother's milk is absorbed by the villi 
of the intestines, and it is with this fluid alone that the chorion villi 
are in direct contact. The sheath thus formed to each villus is 
doubtless analogous to the layer of cells which Goodsir described as 
encasing each villus, but is attributed to a new structure formed after 
conception. 

The existence of the maternal sinus system in the placenta is alto- 
gether denied by anatomists of eminence whose views are worthy of 
careful consideration. Prominent amongst these is Braxton Hicks, 1 
who has written an elaborate paper on the subject. He holds that 
there is no evidence to prove that the maternal blood is poured out 
into a cavity in which the chorion villi float, and he believes that the 
curling arteries, instead of entering the so-called maternal portion of 
the placenta, terminate in the decidua serotina. The hypertrophied 
chorion villi at the site of the placenta are firmly attached to the 
decidual surface, into which their tips are imbedded. The line of 
junction between the decidua reflexa and serotina forms a circum- 
ferential margin to, and limits, the placenta. The arrangement of 
the foetal portion of the placenta on this view is very similar to that 
generally described, but the villi are not surrounded by maternal blood 
at all, and nothing exists between them, unless it be a small quantity 
of serous fluid. The change in the foetal blood is effected by endos- 
mosis, and Hicks suggests that the follicles of the decidua may secrete 
a fluid, which is poured into the intervillous spaces for absorption by 
the villi. 

Functions of the Placenta. — It will thus be seen that anatomists 
of repute are still undecided as to important points in the minute 
anatomy of the placenta, which further investigation will doubtless 
clear up. The main functions of the organ are, however, sufficiently 
clear. During the entire period of its existence it fills the important 
office of both stomach and lungs to the foetus. Whatever view of the 
arrangement of the maternal bloodvessels be taken, it is certain that 
the foetal blood is propelled by the pulsations of the foetal heart into 
the numberless villi of the chorion, where it is brought into very 
intimate relation with the mother's blood, gives off its carbonic acid, 
absorbs oxygen, and passes back to the foetus, through the umbilical 
vein, in a fit state for circulation. The mode of respiration, therefore, 
in the foetus is analogous to that in fishes, the chorion villi represent- 
ing the gills, the maternal blood the water in which they float. Nutri- 
tion is also effected in the organ, and, by absorption through the 
chorion villi, the pabulum for the nourishment of the foetus is taken 
up. It also probably serves as an emunctory for the products of 
excretion in the foetus. Picard found that the blood in the placenta 
contained an appreciably larger Cjiiantity of urea than that in other 
parts of the body, this urea probably being derived from the foetus. 

Obst. Trans., 1S73, vol. xiv. p. 149. 



CONCEPTION AND GENERATION. 121 

Claude Bernard also attributed to it a glycogenic function, 1 supposing 
it to take the place of the foetal liver until that organ was sufficiently 

developed. 

Finally, we find that the temporary character of the placenta is 

indicated by certain degenerative changes, which take place in it 
previous to expulsion. These consist chiefly in the deposil of cal- 
careous patches on its uterine surface, and in fatty degeneration of the 
villi and of the decidual layer between the placenta and the uterus. 

If this degeneration be carried to excess, as is not unfrequently the 
case, the foetus may perish from want of a sufficient number "t* 
healthy villi through which its respiration and nutrition may be 
effected. 

The umbilical cord is the channel of communication between the 
foetus and placenta, being attached to the former at the umbilicus, t<> 
the latter generally near its centre, but sometimes, as in the battledore 
placenta, at its edge. It varies much in length, measuring on an 
average from eighteen to twenty-four inches, but in exceptional cases 
being found as long as fifty or sixty, and as short as five or -ix 
inches. 

When fully formed it consists of an external membranous layer 
formed of the amnion, two umbilical arteries, one umbilical vein, and 
a considerable quantity of a transparent gelatinous substance surround- 
ing the vessels, called AVharton's jelly, which is contained in a fine 
network of fibres, and is formed from the somato-pleural layer of the 
mesoblast in the cord. At an early period of pregnancy, in addition 
to these structures, the cord contains the pedicle of the umbilical 
vesicle, with the omphalo-mesenteric vessels ramifying on it, and 
two umbilical veins, one of which soon atrophies and disappears. No 
nerves or lymphatics have been satisfactorily demonstrated in the 
cord, although such have been described as existing. The vessels of 
the cord are at first straight in their course, but shortly they become 
greatly twisted, the arteries being external to the vein, and in nine 
cases out of ten the twist is from left to right. Various explanations 
have been given of this peculiarity, none of them entirely satisfactory. 
Tyler Smith attributed it to the movements of the foetus twisting the 
cord, its attachment to the placenta being a fixed point ; this would 
not, however, account for the frequency with which the spiral turns 
occur in one direction. Mr. John Simpson attributed it to the greater 
pressure of the blood through the right hypogastric artery, on account 
of that vessel having a more direct relation to the aorta than the left. 
The umbilical arteries give off no branches, and the vein contains no 
valves, nor can any vasa vasorum be detected in their coats after they 
have left the umbilicus. The umbilical arteries increase in size after 
they leave the cord, to divide on the surface of the placenta. This is 
the onlv example in the body in which arteries are larger near their 
terminations than their origin, and the object of this arrangement is 
probablv to effect a retardation of the current of the blood distributed 
to the placenta. The tortuous course of the vein probably compensates 

1 Acad, des Sciences, April, 1859. 



122 PREGNANCY. 

for the absence of valves, and moderates the flow of blood through 
It. 1 

Distinct knots are not unfrequently observed in the cord, but they 
rarely have the effect of obstructing the circulation through it. They 
no doubt form when the foetus is .very small. They may sometimes 
also be produced in labor by the child being propelled through a coil 
of the cord lying circularly around the os uteri. The so-called false 
knots are merely accidental nodosities due to local enlargements of the 
vessels. 



CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

It is obviously impossible to attempt anything like a full account 
of the development of the various foetal structures, or of their growth 
during intra-uterine life. To do so would lead us far beyond the 
scope of this work, and would involve a study of complex details only 
suitable in a treatise on embryology. It is of importance, however, 
that the practitioner should have it in his power to determine approxi- 
mately the age of the foetus in abortions or premature labors, and for 
this purpose it is necessary to describe briefly the appearance of the 
foetus at various stages of its growth. 

1st Month. The foetus in the first month of gestation is a minute 
gelatinous and semi-transparent mass, of a grayish color, in which no 
definite structure can be made out, and in which no head or extremities 
can be seen. It is rarely to be detected in abortions, being lost in 
surrounding blood-clots. In the few examples which have been care- 
fully examined it did not measure more than a line in length. It is, 
however, already surrounded by the amnion, and the pedicle of the 
umbilical vesicle can be traced into the unclosed abdominal cavity. 

2d Month. The embryo becomes more distinctly apparent, and is 
curved on itself, weighing about sixty-two grains, and measuring six 
to eight lines in length. The head and extremities are distinctly vis- 
ible — the latter in the form of rudimentary projections from the body. 
The eyes are to be seen as small black spots on the side of the head. 
The spinal column is divided into separate vertebrae. The indepen- 
dent circulatory system of the foetus is now beginning to form, the 
heart consisting of only one ventricle and one auricle, from the former 
of which both the aorta and pulmonary arteries arise. On either side 
of the vertebral column, reaching from the heart to the pelvis, are two 

f 1 In some instances the disproportionate length of the vein causes the cord to assume a screw- 
like form, which may be very regular, as is exhibited to a remarkable degree by one in my 
possession, in which there are between thirty and forty turns, involving the whole funis, which is 
of average length in a straight line.— Ed.] 



ANATOMY AND PHYSIOLOGY OP THE FOETUS. 123 

large glandular structures, the corpora Wolffiana } which consisl of a 
series of convoluted mho opening into an excretory duct, running 

along their external border-, and connected below with the common 
cloaca of the genito-urinary and digestive tracts. They seem to ad as 
secreting glands, and fulfil the function- of the kidneys before they 
are formed. Toward the end of the second month they atrophy and 
disappear, and the only trace of them in the foetus :il term is to he 
found in tin 1 parovarium lying between the folds of the broad liga- 
ments. At this stage of development there are met with in the human 
embryo, as in that of all mammals, four transverse fissures opening 
into the pharynx, which are analogous to the permanent branchiae of 
fishes. Their vascular supply is also similar, as the aorta at this time 
gives off four branches on each side, each of which forms a branchial 
arch, and these afterward unite to form the descending aorta. By the 
end of the sixth week these, as well as the transverse fissures to which 
they are distributed, disappear. By the end of the second month the 
kidneys and supra-renal capsules are forming, and the single ventricle 
is divided into two by the growth of the inter-ventricular septum. 
The umbilical cord is quite straight, and is inserted into the lower 
part of the abdomen. Centres of ossification are showing themselves 
in the inferior maxillary bones and the clavicle. 

3d Month. The embryo weighs from seventy to three hundred 
grains, and measures from two and a half to three and a half inches 
in length. The forearm is well formed, and the first traces of the 
fingers can be made out. The head is large in proportion to the rest 
of the body, and the eyes are prominent ; the mouth is closed by the 
lips, and is separated by them from the nasal cavity. The umbilical 
vesicle and allantois have disappeared, and the alimentary canal is 
now situated entirely within the abdominal cavity. The greater 
portion of the chorion villi have atrophied, and the placenta is 
distinctly formed. 

4th Month. The weight is from four to six ounces, and the length 
about six inches. The convolutions of the brain are beginning to 
develop. The sex of the child can now be ascertained on inspection. 
Hairs begin to be formed on the head. The muscles are sufficient! v 
formed to produce distinct movements of the limbs. Ossification is 
extending, and can be traced in the occipital and frontal bones, and in 
the mastoid processes. The sexual organs are differentiated. 

5th Month. Weight about ten ounces. Length, nine or ten inches. 
Hair is observed covering the head, which forms about one-third of 
the length of the whole foetus. The nails are beginning to form, and 
ossification has commenced in the ischium. The foetal movements are 
distinct, and in cases of premature delivery, may continue for some 
time after the birth of the child. 

6th Month. AVeight about one pound. Length, eleven to twelve 
and a half inches. The hair is darker. The eyelids arc closed, and 
the membrana pupillaris exists; eyelashes have now been formed. 
Some fat is deposited tinder the skin. The testicle- are Mill in the 
abdominal cavity. The clitoris is prominent. The pubic bono have 
begun to ossify. 



124 PREGNANCY. 

7th Month. Weight from three to four pounds. Length, thirteen 
to fifteen inches. The skin is covered with unctuous, sebaceous matter, 
and there is a more considerable deposit of subcutaneous fat. The 
eyelids are open. The testicles have descended into the scrotum. 
Children born at this time may occasionally survive. 

Sth Month. Weight from four to five pounds. Length, sixteen to 
eighteen inches, and the foetus seems now to grow in thickness rather 
than in length. The nails are completely developed. The membrana 
pupillaris has disappeared. 

Foetus at Term. — At the completion of pregnancy the foetus weighs 
on an average, six and a half pounds, and measures about twenty 
inches in length. These averages are, however, liable to great varia- 
tion. Remarkable histories are given by many writers of foetuses of 
extraordinary weight, which have been probably greatly exaggerated. 
Out of 3000 children delivered under the care of Cazeaux at various 
charities, one only weighed ten pounds. There are, however, several 
carefully recorded instances of weight far exceeding this ; but they are 
undoubtedly much more uncommon than is generally supposed. Dr. 
Ramsbottom mentions a foetus weighing sixteen and a half pounds ; 
Cazeaux tells us of one which he delivered by turning, which weighed 
eighteen pounds and measured two feet one and a half inches; and 
the birth of one weighing twenty-one pounds has been recentlv 
recorded. 1 Such overgrown children are almost invariably stillborn. 2 

The average size of male children at birth, as in after-life, is some- 
what greater than that of female. Thus Simpson 3 found that out of 
100 cases the male children averaged ten ounces more in weight than 
the female, and half an inch more in length. 

[Some mothers of average size never bear a foetus of even six pounds 
in weight, although begotten bv a husband of full vigor. One of my 
patients bore a daughter of three and a half pounds ; a second of two 
and three-quarters ; and a son of five and a half pounds. The first 
daughter has given birth to a girl of one and a half pounds, now living 
at the age of two. The second died at eight months ; and the son is 
a vigorous youth of sixteen. Such small children sometimes grow to 
very large size and live to advanced age, as witness the fact that one 
in this city became a large, tall woman, and died at the age of eighty- 
seven years. — Ed.] 

A newborn child at term is generally covered to a greater or less 
extent with a greasy, unctuous material, the vernix caseosa, which is 
formed of epithelial scales and the secretion of the sebaceous glands, 
and which is said to be of use in labor by lubricating the surface of 
the child. The head is generally covered with long dark hair, which 

i Brit. Med. Journ., Feb. 1, 1879. 

2 Probably the largest fcetus on record was that of Mrs. Captain Bates, the Xova Scotia giantess, 
a woman of seven feet nine inches, whose husband is also of gigantic build, reaching seven feet 
seven inches in height. This child, born in Ohio, was their second, and was lost in its birth, as 
no forceps could be procured of sufficient size to grasp the head. The fcetus weighed twenty-three 
and three-quarter pounds, and was thirty inches in length. Their first infant weighed eighteen 
pounds. We have had children born in this city (Philadelphia') at maturity and live, that weighed 
but one pound. The well-remembered " Pincus baby " weighed a pound and an ounce. (Harris, 
note to 3d American edition). 

3 Selected Obstetrical Works, p. 327. 



ANATOMY AND PHYSIOLOGY OF THE FGETU8. i 25 

frequently fells off or changes in color shortly utter birth. Dr. Wilt- 
shire 1 has called attention to an old observation, that the eyes of all 
newborn children are of a peculiar dark steel-gray color, and thai 
they do not acquire their permanent tint until some time after birth, 

The umbilical cord is generally inserted below the centre of the 
body. 

Anatomy of the Foetal Head. — The most important pail of the 
foetus from an obstetrical point of view is the head, which requires a 
separate study, as it is the usual presenting part, and the facility of 
the labor depends on its accurate adaptation to the maternal pass 

The chief anatomical peculiarity of interest, in the head of the foetus 
at term, is that the bones of the skull, especially of its vertex — which, 
in the vast majority of cases, has to pass first through the pelvis — are 
not firmly ossified as in adult life, but are joined loosely together by 
membrane or cartilage. The resnlt of this is that the skull is capable 
of being moulded and altered in form to a very considerable extent by 
the pressnre to which it is subjected, and thus its passage through the 
pelvis is very greatly facilitated. This, however, is chiefly the case 
with the craninm proper, the bones of the face and of the base of the 
skull being more firmly united. By this means the delicate structures 
at the base of the brain are protected from pressnre, while the change 
of form which the sknll undergoes during labor implicates a portion 
of the skull where pressure ou the cranial contents is least likely to be 
injurious. 

The divisions between the bones of the cranium are further of 
obstetric importance in enabling us to detect the precise position of the 
head during labor, and an accurate knowledge of them is therefore 
essential to the obstetrician. 

AVe talk of them as sutures and fontanelles : the former being the 
lines of junction between the separate bones, which overlap each other 
to a greater or less extent during labor ; the latter, membranous inter- 
spaces where the sutures join each other. 

The principal sutures are: 1st. The sagittal, which separates the 
two parietal bones, and extends longitudinally backward along the 
vertex of the head. 2d. The frontal, which is a continuation of the 
sagittal, and divides the two halves of the frontal bone, at this time 
separate from each other. 3d. The coronal, which separates the frontal 
from the parietal bones, and extends from the squamous portion of the 
temporal bone across the head to a corresponding point on the opposite 
side. 4th. The lambdoldal, which receives its name from its resem- 
blance to the Greek letter A, and separates the occipital from the 
parietal bones on either side. The fontanelles (Fig. 65) are the mem- 
branous interspaces where the sutures join — the anterior and larger 
being lozenge-shaped, and formed by the junction of the frontal. 
sagittal, and two halves of the coronal sutures. It will be well to note 
that there are, therefore, four line- of sutures running into it, and four 
angles, of which the anterior, formed by the frontal suture, is most 
elongated and well marked. The posterior fontanelle (Fig. '!<!) is 

1 Lancet, February 11, 1871. 



126 



PREGNANCY. 



formed by the junction of the sagittal suture with the two legs of the 
lambdoidal. It is, therefore, triangular in shape, with three lines of 
sutures entering it in three angles, and is much smaller than the an- 
terior fontanelle, forming merely a depression into which the tip of the 
finger can be placed, while the latter is a hollow as big as a shilling, 
or even larger. As it is the posterior fontanelle which is generally 



Fig. 65. 



Fig. 66. 





Anterior and posterior fontanelles. 



Bi-parietal diameter, sagittal and 
lambdoidal sutures, with posterior 
fontanelle. 



Fig. 



lowest, and the one most commonly felt during labor, it is important 
for the student to familiarize himself with it, and he should lose no 
opportunity of studying the sensations imparted to the finger by the 
sutures and fontanelles in the head of the child after birth. 

The Diameters of the Fcetal Skull. — For the purpose of under- 
standing the mechanism of labor, we must study the measurements of 

the foetal head in relation to the 
cavity through which it has to 
pass. They are taken from corre- 
sponding points opposite to each 
other, and are known as the 
diameters of the skull (Fig. 67). 
Those of most importance are : 
1st. The occipito-mentalis (o.m), 
from the occipital protuberance to 
the point of the chin, 5.25" to 
5. 50". 2d. The occipito-frontalis 
(o. f), from the occiput to the 
centre of the forehead, 4.50" to 
5". 3d. The sub-occipito-breg- 
matica (s. o. b), from a point mid- 
way between the occipital pro- 
tuberance and the margin of the 
foramen magnum to the centre of 
the anterior fontanelle, 3. 25". 4th. The cervico-bregmatica (c.b), from 
the anterior margin of the foramen magnum to the centre of the 
anterior fontanelle, 3.75". 5th. Transverse, or bi-parietalis (bi-p), 




1—2. Diameter occipito-frontalis (o.F). 
3 — 4. " occipito-mentalis (o.M). 

5—6. " cervico-bregmatica (c.b). 

7—8. " fronto-mentalis (f.m). 



ANATOMY AND PHYSIOLOGY OF THE PCBTUS. L27 

between the parietal protuberances, 3.75" to I". 6th. Bi-temporalis 
(bi-t), between the ears, 3.50". 7th. Fronlo-merUalw (p.m), from the 
apex of the forehead to the chin, : , >.i ) -7 / . 

The length of these respective diameters, as given by different 
writers, differs considerably — a fact to be explained by the measure- 
ments having been taken at different times ; by some just after birth, 
when the head was altered in shape by the moulding it had undergone; 
by others when this had either been slight, or after the head had 
recovered it- normal shape. The above measurements may he taken as 
the average of those of the normally shaped head, and it is to be 
noted that the first two are most apt to he modified during labor. The 
amount of compression and moulding to which the head may he sub- 
jected, without proving fatal to the foetus, is not certainly known, hut 
it is doubtless very considerable. Some interesting example- of the 
extent to which the head may be altered in shape in difficult labors 
have been given by Barnes/ who has shown by tracings of the shape 
of the head taken immediately after delivery, that in protracted labor 
the occipito-mental (o. m) and occipitofrontal (o. f) diameters may be 
increased more than an inch iu length, while lateral compression may 
diminish the bi-parietal (bi-p) diameter to the same length as the 
inter-auricular. The foetal head is movable on the vertical column to 
the extent of a quarter of a circle ; and it seems probable that the 
laxity of the ligaments admits with impunity a greater circular move- 
ment than would be possible in the adult. 

On taking the average of a large number of measurements, it is 
found that the heads of male children are larger and more nrmly 
ossified than those of females, the former averaging about half an 
inch more in circumference. Sir James Simpson attributed great 
importance to this fact, and believed that it was sufficient to account 
for the larger proportion of stillbirths in male than in female chil- 
dren, as well as for the greater difficulty of labor and the increased 
maternal mortality that are found to attend on male births. His 
well-known paper on this subject, which has given rise to much con- 
troversy, is full of the most elaborate details, and so great did he 
believe the foetal influence to be, that he calculated that between 
the years 1834 and 1837 there were lost in Great Britain, as a conse- 
quence of the slightly larger size of the male than of the female head 
at birth, about 50,000 lives, including those of about 46,000 or 47,000 
infants, and of between 3000 and 4000 mothers who died in childbed.-' 
It is probable that race and other conditions, such as civilization and 
intellectual culture, have considerable influence on the si/o of the fetal 
skull, but we are not in possession of sufficiently accurate data t< > j u>- 
tifv any very positive opinion on these points. 

In the very large majority of cases the foetus lies in utero with head 
downward, and i< so placed a- to be adapted in the most convenient 
way to the cavity in which it is placed. The uterine cavity is most 
roomv at the fundus, and narrowest at the cervix, and the greatest 
bulk of the fetus is at the breech, so that the largest part of' the child 

i Obst. Trans . vii. p. 171. 3etected Obst Work-. \>. 363. 



128 PREGNANCY. 

usually lies in the part of the uterus best adapted to contain it. The 
various parts of the child's body are, further, so placed in regard to 
each other as to take up the least possible amount of space. (See 
Plates I., II.) The body is bent so that the spine is curved with its 
convexity outward, this curvature existing from the earliest period of 
development ; the chin is flexed on the sternum ; the forearms are 
flexed on the arms, and lie close together on the front of the chest ; 
the legs are flexed on the thighs, and the thighs drawn up on the 
abdomen ; the feet are drawn up toward the legs ; the umbilical cord 
is generally placed out of reach of injurious pressure, in the space 
between the arms and the thighs. Variations from this attitude, 
however, are not uncommon, and are not, as a rule, of much con- 
sequence. Although the cranial presentations are much the most 
common, averaging 86 out of every 100 cases, other presentations are 
by no means rare, the next most frequent being either that of the 
breech, in which the long diameter of the child lies in the long diam- 
eter of the uterine cavity ; or some variety of transverse presentation, 
in which the long diameter of the foetus lies obliquely across the uterus, 
and no longer corresponds to its longitudinal axis. 

It was long believed that the head presentation was only assumed 
toward the end of pregnancy, when it was supposed to be produced 
by a sudden movement on the part of the foetus, known as the culbute. 
It is now well known that, in the large majority of cases, the head is 
lowest during all the latter part of pregnancy, although changes in 
position are more common than is generally believed to be the case, 
and presentation of parts other than the head is much more frequent 
in premature labor than in delivery at term. In evidence of the last 
statement, Churchill says that in labor at the seventh month the head 
presents only 83 times out of 100 when the child is living, and that 
as many as 53 per cent, of the presentations are preternatural when 
the child is stillborn. The frequency with which the foetus changes 
its position before delivery has been made the subject of investigation 
by various German obstetricians, and the fact can be readily ascertained 
by examination. Valenta 1 found that out of nearly 1000 cases, care- 
fully and frequently examined by him, in 57.6 per cent, the presenta- 
tion underwent no change in the latter months of pregnancy, but in 
the remaining 42.4 per cent, a change could be readily detected. 
These alterations were found to be most frequent in multipara?, and 
the tendency was for abnormal presentations to alter into normal ones. 
Thus it was common for transverse presentations to alter longitudinally, 
and but rare for breech presentations to change into head. The ease 
with which these changes are effected no doubt depends, in a con- 
siderable degree, on the laxity of the uterine parietes, and on the 
greater quantity of amniotic fluid, by both of which the free mobility 
of the foetus is favored. 

The facility witli which the position of the foetus in utero can be 
ascertained by abdominal palpation has not been generally appreciated 

i Monats. f. Geburt., 1865, Bd. sxiv. S. 172; and 1866, Bd. xxviii. S. 361. " Geburtshulfliche 
Studien." 



ANATOMY AND PHYSIOLOGY OF THE FCBTUS 



L29 



in obstetric works, and yet, by a little practice, it is easy to make it 
out. Much information <>!' importance can be gained in this way, and 
it is quite possible, under favorable circumstances, to alter abnormal 
presentations before labor has begun. For the purpose of making 
this examination, the patient should lie at the edge of the bed, with 
her shoulders slightly raised, and the abdomen uncovered. The first 
observation to make is to see if the longitudinal axis of the uterine 
tumor corresponds with that of the mother's abdomen ; if it does, the 
presentation must be either a head or a breech. By spreading the 
hands over the uterus (Fig. 68), a greater sense of resistance can be 

Fig. 68. 




Mode of ascertaining the position of the fcetus bv palpation. 

felt, in most cases, on one side than on the other, corresponding to the 
back of the child. By striking the tips of the fingers suddenly inward 
at the fundus, the hard breech can generally be made out, or the head 
still more easily, if the breech be downward. When the uterine Avails 
are unusually lax, it is often possible to feel the limbs of the child. 
These observations can be generally corroborated by auscultation, for 
in head presentations the foetal heart can usually be heard below the 
umbilicus, and in breech cases above it. Transverse presentations can 
even more easily be made out by abdominal palpation. Here the 
long axis of the uterine tumor does not correspond with the long axis 
of the mother's abdomen, but lies obliquely across it. By palpation 
the rounded mass of the head can be easily felt in one of the mother's 
flanks, and the breech in the other, while the foetal heart is heard 
pulsating nearer to the side at which the head is detected. 

The reason why the head presents so frequently has been made the 
subject of much discussion. The oldest theory was, that the head lay 
over the os uteri as the result of gravitation, and the influence of 
gravity, although contested by many obstetricians, prominent among 
whom were Dubois and Simpson, has been insisted upon as the chief 

9 



130 



PREGNANCY 



cause by others, Dr. Duncan being one of the most strenuous advo- 
cates of this view. The objections urged against the gravitation theory 
were drawn partly from the result of experiments, and partly from 
the frequency with which abnormal presentations occur in premature 
labors, when the action of gravity cannot be supposed to be suspended. 
The experiments made by Dubois went to show, that when the foetus 
was suspended in water, gravitation caused the shoulders, and not the 
head, to fall lowest. He, therefore, advanced the hypothesis that the 
position of the foetus was due to instinctive movements, which it made 
to adapt itself to the most comfortable position in which it could lie. 
It need only be remarked that there is not the slightest evidence of 
the foetus possessing any such power. Simpson proposed a theory 
which was much more plausible. He assumed that the foetal position 
was due to reflex movements produced by physical irritations to 
which the cutaneous surface of the foetus is subjected from changes 
of the mother's position, uterine contractions, and the like. The 
absence of these movements, in the case of the death of the foetus, 
would readily explain the frequency of malpresentations under such 
circumstances. 

The obvious objection to this theory, complete as it seems to be, is 
the absence of any proof that such constant extensive reflex movements 




Diagram illustrating the effect of gravity on the foetus, a, b, is parallel to the axis of the preg- 
nant uterus and pelvic hrim. c, d, e, is a perpendicular line, e, the centre of gravity of the 
foetus, d, the centre of flotation. (After Duncan.) 

really do occur in utero. Dr. Duncan has very conclusively disposed 
of the principal objections which have been raised against the influence 
of gravitation, and, when an obvious explanation of so simple a kind 
exists, it seems useless to seek further for another. He has shown 
that Dubois's experiments did not accurately represent the state of the 
foetus in utero, and that during the greater part of the day, when the 
woman is upright, or lying on her back, the foetus lies obliquely to 
the horizon at an angle of about 30°. The child thus lies, in the 
former case, on an inclined plane, formed by the anterior uterine Avail 



ANATOMY AND PHYSIOLOGY OF T II E PGBTUS. 



i:;i 



and the abdominal parietes, in the latter by the posterior uterine 
wall and the vertebral column. Down the inclined plane so formed 
the force of gravity causes the foetus to slide, and it is only when the 
woman lies on her side that the fcetus is placed horizontally, and is 
not subjected in the same degree to the net ion of gravity (Fig. 69). 
The frequency of Dial-presentations in premature Labors is explained 
by Dr. Duncan partly by the fact that the death of the child (which 
so frequently precedes such cases) alters its centre of gravity, and 
partly by the prater mobility of the child and the greater relative 
amount of liquor amnii (Fig. 70). The effect of gravitation is probably 

Fig. 70. 




Illustrating the greater mobility of the foetus and the larger relative amount of liquor amnii in 
early pregnancy, a, b. Axis of pregnant uterus, b, h. A horizontal line. (After Duncan.) 

greatly assisted by the contractions of the uterus which are going on 
during the greater part of pregnancy. The influence of these was 
pointed out by Dr. Tyler Smith, who distinctly showed that the contrac- 
tions of the uterus preceding delivery exerted a moulding or adapting 
influence on the foetus, and prevented undue alterations of its position. 
Dr. Hicks proved l that these uterine contractions are of constant occur- 
rence from the earliest period of pregnancy, and there can be little 
doubt that they must have an important influence on the body contained 
within the uterus. The whole subject has been recently considered 
by Pinard, 2 who shows that many factors are in action to produce and 
maintain the usual position of the foetus in utero, which may be either 
of an active or a passive character : the former being chiefly the active 
movements of the foetus and the contractions of the uterus and the 
abdominal muscles ; the latter, the form of the uterus and the foetus, 
the slippery surface of the amnion, pressure of the amniotic fluid, etc. 
When any of these factors are at fault, mal-presentation is apt to 
occur. 

The functions of the foetus are in the main the same, with differ- 
ences depending on the situation in which it is placed, as those of the 
separate being. It breathes, it is nourished, it forms secretions, and 



i Obst. Trans., 1872. vol. xiii. p. 216. 
2 Annal. de Gyn., 1878, torn. ix. i». .521. 



132 PREGNANCY. 

its nervous system acts. The mode in which some of these functions 
are carried on in intra-uterine life requires separate consideration. 

Nutrition. — During the early part of pregnancy, and before the 
formation of the umbilical vesicle and the allantois, it is certain that 
nutritive material must be supplied to the ovum by endosmosis 
through its external envelope. The precise source, however, from 
which this is obtained is not positively known. By some it is believed 
to be derived from the granulations of the discus proligerus which 
surround it as it escapes from the Graafian follicle, and subsequently 
from the layer of albuminous matter which surrounds the ovum before 
it reaches the uterus ; while others think it probable that it may come 
from a special liquid secreted by the interior of the Fallopian tube as 
the ovum passes along it. As soon as the ovum has reached the 
uterus, there is every reason to believe that the umbilical vesicle is the 
chief source of nourishment to the embryo, through the channel of 
the omphalo-mesenteric vessels, which convey matters absorbed from 
the interior of the vesicle to the intestinal canal of the foetus. At this 
time the exterior of the ovum is covered by numerous fine villosities 
of the primitive chorion, which are imbedded in the mucous mem- 
brane of the uterus, and it is thought that they may absorb materials 
from the maternal system, which may be either directly absorbed by 
the embryo, or which may serve the purpose of replacing the nutritive 
matter which has been removed from the umbilical vesicle by the 
omphalo-mesenteric vessels. This point it is, of course, impossible to 
decide. Joulin, however, thinks that these villi probably have no 
direct influence on the nourishment of the foetus, which is at this time 
solely effected by the umbilical vesicle, but that they absorb fluid from 
the maternal system, which passes through the amnion and forms the 
liquor amnii. As soon as the allantois is developed, vascular com- 
munication between the foetus and the maternal structures is estab- 
lished, and the temporary function of the umbilical vesicle is over ; 
that structure, therefore, rapidly atrophies and disappears, and the 
nutrition of the foetus is now solely carried on by means of the chorion 
villi, lined as they now are by the vascular endochorion, and chiefly 
by those which go to form the substance of the placenta. 

This statement is opposed to the views of many physiologists, who 
believe that a certain amount of nutritive material is conveyed to the 
foetus through the channel of the liquor amnii, itself derived from the 
maternal system, which is supposed either to be absorbed through 
the cutaneous surface of the foetus, or carried to the intestinal canal 
by deglutition. The reasons for assigning to the liquor amnii a nutri- 
tive function are, however, so slight, that it is difficult to believe that it 
has any appreciable action in this way. They are based on some ques- 
tionable observations, such as those of Weydlich, who kept a calf alive 
for fifteen days by feeding it solely on liquor amnii, and the experi- 
ments of Burdach, who found the cutaneous lymphatics engorged in a 
foetus removed from the amniotic cavity, while those of the intestine 
were empty. The deglutition of the liquor amnii for the purposes of 
nutrition has been assumed from its occasional detection in the stomach 
of the foetus, the presence of which may, however, be readily explained 



ANATOMY AND PHYSIOLOGY OF l II K FCETUS. 133 

by spasmodic efforts at respiration, which the foetus undoubtedly often 
makes before birth, especially when the placental circulation is in any 
way interfered with, and during which a certain quantity of fluid 
would necessarily be -wallowed. The quantity of nutritive material, 
however, in the liquor amnii i- -<> -mall — qo1 more than <; t<> !» parts 
of albumin in 1000 — that it is impossible to conceive that it could 
have any appreciable influence in nutrition, even if its absoption 
either by the skin or stomach were susceptible of proof. 

That the nutrition of the fetus is effected through the placenta is 
proved by the common observation that whenever the placental circu- 
lation is arrested, as by disease of its structure, the foetus atrophies 
and dies. The precise mode, however, in which nutritive materials 
are absorbed from the maternal blood is still a matter of doubt, and 
must remain so until the mooted points as to the minute anatomy of 
the placenta are settled. The various theories entertained on this 
subject by the upholders of the Hunterian doctrine of placental 
anatomy, and by those who deny the existence of a sinus svstein, have 
already been referred to in the chapter on the Anatomy of the 
Placenta, to which the reader is referred (pp. 115-122). 

Respiration. — One of the chief functions of the placenta, besides 
that of nutrition, is the supply of oxygenated blood to the foetus. 
That this is essential to the vitality of the foetus, and that the placenta 
is the site of oxygenation, is shown by the fact that whenever the 
placenta is separated, or the access of foetal blood to it arrested by 
compression of the cord, instinctive attempts at inspiration are made, 
and if aerial respiration cannot be performed, the foetus is expelled 
asphyxiated. Like the other functions of the foetus during intra- 
uterine life, that of respiration has been made the subject of numerous 
more or less ingenious hypotheses. Thus many have believed that 
the foetus absorbed gaseous material from the liquor amnii, which 
served the purpose of oxygenating its blood, St. Hilaire thinking that 
this was effected by minute openings in its skin, Beclard and others 
through the bronchi, to which they believed the liquor amnii gained 
access. Independently of the entire want of evidence of the absorption 
of gaseous materials by these channels, the theory is disproved by the 
fact that the liquor amnii contains no air which is capable of respira- 
tion. Serres attributed a similar function to some of the chorion villi, 
which he believed penetrated the utricular glands of the decidua reflexa 
and absorbed gas from the hydroperione, or fluid situated between 
it and the decidua vera, and in this manner he thought the foetal blood 
was oxygenated until the fifth month of intra-uterine life, when the 
placenta was fully formed. 

This hypothesis, however, rests on no accurate foundation, for it is 
certain that the chorion villi do not penetrate the utricular glands in the 
manner assumed ; or, even if they did, the mode in which the oxygen 
thus absorbed by the chorion villi reaches t 1 1 < ■ foetus, which is separated 
from them by the amnion and its contents, would still remain 
unexplained. 

The mode in which the oxygenation of the foetal blood is effected 
before the formation of the placenta remains, therefore, as yet tin- 



134 PREGNAXCY. 

known. After the development of that organ, however, it is less 
difficult to understand, for the foetal blood is everywhere brought into 
such close contact with the maternal, in the numerous minute ramifica- 
tions of the umbilical vessels, that the interchange of gases can readily 
be effected. The activity of respiration is doubtless much less than in 
extra-uterine life, for the Avaste of tissue in the foetus is necessarily 
comparatively small, from the fact of its being suspended in a fluid 
medium of its own temperature, and from the absence of the processes 
of digestion and of respiratory movements. The quantity of carbonic 
acid formed would, therefore, be much less than after birth, and there 
would be a correspondingly small call for oxygenation of venous 
circulation. 

Circulation. — The functions of the lungs being in abeyance, it is 
necessary that all the foetal blood should be carried to the placenta 
to receive oxygen and nutritive materials. To understand the mode 
in which this is effected we must bear in mind certain peculiarities in 
the circulatory system which disappear after birth. 

1. The two sides of the foetal heart are not separate as in the adult. 
The right ventricle in the adult sends all the venous blood to the 
lungs through the pulmonary arteries, to be aerated by contact with 
the atmosphere. In the foetus,' however, only sufficient blood is passed 
through the pulmonary arteries to insure their being pervious and 
ready to carry blood to the lungs immediately after birth. 

An aperture of communication, the foramen ovale, exists between the 
two auricles, which is arranged so as to permit the blood reaching the 
right auricle to pass freely into the left, but not vice versa. By this 
means a large portion of the blood reaching the heart through the 
venae cavae, instead of passing, as in the adult, into the right ventricle, 
is directed into the right auricle. 

2. Even with this arrangement, however, a larger portion of blood 
would pass into the pulmonary arteries than is required for trans- 
mission to the lungs, and a further provision is made to prevent its 

going to them by means of a foetal vessel, the 
FlG - 7L ductus arteriosus (Fig. 71), which arises from the 

point of bifurcation of the pulmonary arteries, 
and opens into the arch of the aorta. In con- 
sequence of this arrangement only a very small 
portion of the blood reaches the lungs at all. 

3. The foetal hypogastric arteries are continued 

into large arterial trunks, which, passing into the 

cord, form the umbilical arteries, and carry the 

Diagram of foetal heart, impure foetal blood into tita placenta. 

l. Aorta. 2. Pulmonary 4. The purified blood is collected into the 

artery. 3, 3. Pulmonary s j n ole umbilical vein, through which it is carried 

branches. 4. Ductus ar- » , pp.ii- n i • i • , 

teriosus. (After dalton.) to the under suriace ot the liver, trom which point 
it is conducted, by means of another special foetal 
vessel, the ductus venosus, into the ascending vena cava and the right 
auricle. 

In order to understand the course of the foetal blood it may be 
most conveniently traced from the point where it reaches the under 




ANATOMY AND PHYSIOLOGY OF THE PCETUS. L36 

surface of the liver through the umbilica] vein. Pari of i1 is dis- 
tributed to the liver itself, bu1 the greater quantity is carried directly into 
the inferior vena cava, through the ductus venosus. The inferior vena 
cava also receives the blood from the fetal veins of the lower extremi- 
ties, and that portion of the blood of the umbilical vein which has 
passed through the liver. This mixed blood is carried up to the fighl 
auricle, from which by far the greater part of it is immediately directed 
into the left auricle, through the foramen ovale. From thence it 
passes into the left ventricle, which sends the greater pari of it into the 
head and upper extremities through the aorta, a comparatively small 
quantity being transmitted to the inferior extremities. The blood 
which is thus sent to the upper part of the body is collected into the 
vena cava superior, by which it is thrown into the righl auricle. 
Here the mass of it is probably directed into the right ventricle, which 
expels it into the pulmonary arteries, and from thence, through the 
ductus arteriosus, into the descending aorta. By this arrangement it 
will be seen that the descending aorta conveys to the lower part of the 
body the comparatively impure blood which has already circulated 
through the head, neck, and upper extremities. From the descending 
aorta a small quantity of blood is conveyed to the lower extremities, 
the greater part of it being carried for purification to the placenta 
through the umbilical arteries. 

As soon as the child is born it generally cries loudly and inflates 
its lungs, and, in consequence, the pulmonary arteries a re .dilated and 
the greater portion of the blood of the right ventricle is at once sent 
to the lungs, from whence, after being arterializcd, it is returned to 
the left auricle, through the pulmonary veins. The left auricle, there- 
fore, receives more blood than before, the right less, and, the placental 
circulation being arrested, no more passes through the umbilical vein. 
In consequence of this, the pressure of the blood in the two auricles is 
equalized, the mass of the blood in the right auricle no longer passes 
into the left (the valve of the foramen ovale being closed by the equal 
pressure on both sides), but directly into the right ventricle and from 
thence into the pulmonary arteries, and the ductus arteriosus soon 
collapses and becomes impervious. The mass of blood in the descending 
aorta no longer finds its way into the hypogastric arteries, but passes 
into the lower extremities, and the adult circulation is established. 

The changes which take place in the temporary vascular arrange- 
ments in the foetus, prior to their complete disappearance, are of some 
practical interest. The ductus arteriosus, as has been said, collapses, 
chiefly because the mass of blood is drawn to the lungs, and partly, 
perhaps, by its own inherent contractility. Its walls are found to be 
thickened, and its canal closes, first in the centre, and subsequently at 
its extremities, its aortic end remaining longer pervious on account of 
the greater pressure of blood from the left side of the heart (Fig. 72). 
Practical closure occurs within a few days after birth, although 
Flourens states that it is not completely obliterated until eighteen months 
or two years have elapsed. 1 According to Schroeder it^ walls unite 

1 Acad, des Sciences, 1854. 



136 



PKEGNANCY. 



Fig. 72. 




Diagram of heart of infant. 1. 
Aorta. 2. Pulmonary artery. 3, 3. 
Pulmonary branches. 4. Ductus 
arteriosus becoming obliterated. 
(After D alton.) 



without the formation of any thrombus. The foramen ovale is soon 
closed by its valve, which contracts adhesion with the edges of the 
aperture, so as effectually to occlude it. Sometimes, however, a small 

canal of communication between the two 
auricles may remain pervious for many 
months, or even a year or more, without, 
however, any admixture of blood occurring. 
A permanently patulous condition of this 
aperture, however, sometimes exists, giving 
rise to the disease known as cyanosis. 

The umbilical arteries and veins and the 
ductus venosus soon also become imper- 
meable, in consequence of concentric hyper- 
trophy of their tissue and collapse of their 
walls. The closure of the former is aided 
by the formation of coagula in the interior. 
According to Robin, a longer time than is 
usually supposed elapses before they become 
completely closed, the vein remaining per- 
vious until the twentieth or thirtieth day 
after delivery, the arteries for a month or six weeks. He has also 
described 1 a remarkable contraction of the umbilical vessels within 
their sheaths, at the point where they leave the abdominal walls, 
which takes place within three or four days after birth, and seems to 
prevent hemorrhage taking place when the cord is detached. 

Function of the Liver. — The liver, from its proportionately large 
size, apparently plays an important part in the foetal economy. It is 
not until about the fifth month of utero-gestation that it assumes its 
characteristic structure, and forms bile, previous to that time its texture 
being soft and undeveloped. According to Claude Bernard, after this 
period one of its most important offices is the formation of sugar, which 
is found in much larger amount in the foetus than after birth. Sugar 
is, however, found in the foetal structures long before the development 
of the liver, especially in the mucous and cutaneous tissues, and it 
seems probable that these, as well as the placenta itself, then fulfil the 
glycogenic function, afterward chiefly performed by the liver. The 
bile is secreted after the fifth month of pregnancy, and passes into the 
intestinal canal, and is subsequently collected in the gall-bladder. By 
some physiologists it has been supposed that the liver, during intra- 
uterine life, was the chief seat of depuration of the carbonic acid 
contained in the venous blood of the foetus. It is, however, more 
generally believed that this is accomplished solely in the placenta. 
The bile, mixed with the mucous secretion of the intestinal tract, forms 
the meconium which is contained in the intestines of the foetus, and 
which collects in them during the whole period of intra-uterine life. 
It is a thick, tenacious, greenish substance, which is voided soon after 
birth in considerable quantity. 

The Urine. — Urine is certainly formed during intra-uterine life, as 



i Ibid., 1860. 



PREGNANCY. L37 



u r i~ con- 



is proved by the fad familiar to all accoucheurs, thai the bladd 
stantly emptied instantly after birth. It has generally been supposed 

that the fetus voids its urine into the cavity of the amnion, and the 
existence of traces of urea in the liquor amnii, as well as sonic < ;i 
imperforate urethra, in which the bladder was found to he enormously 
distended, and some cases of congenital hydro-nephrosis associated with 
impervious ureters, have been supposed to corroborate this assumption. 
The question has been very fully studied by Joulin, who lias collected 
together a large number of instances in winch there was imperforate 
urethra without any undue distention of the bladder. He holds also, 
that the amount of urea found in the liquor amnii is far too minute to 
justify the conclusion that the urine of the foetus was habitually passed 
into it, although a small quantity may, he thinks, escape into it from 
time to time; and he therefore believes that the urine of the foetus i- 
only secreted regularly and abundantly after birth, and that during 
intra-uterine life its retention is uot likely to give rise to any functional 
disturbance. 

Function of the Nervous System. — There is no doubt that the 
nervous system acts to a considerable extent during intra-uterine life, 
and some authors have even supposed that the foetus was endowed with 
the power of making instinctive or voluntary movements for the pur- 
pose of adapting itself to the form of the uterine cavity. Most prob- 
ably, however, the movements the foetus performs are purely reflex. 
That it responds to a stimulus applied to the cutaneous nerves is proved 
by the experiments of Tyler Smith, who laid bare the amnion in preg- 
nant rabbits, and found that the foetus moved its limbs when these 
were irritated through it. Pressure on the mother's abdomen, cold 
applications, and similar stimuli will also produce energetic foetal 
movements. The gray matter of the brain in the newborn child is, 
however, quite rudimentary in its structure, and there is no evidence 
of intelligent action of the nervous system until some time after birth, 
and a fortiori during pregnancy. 



CHAPTEE III. 

PREGNANCY. 

Changes in the Uterus. — As soon as conception has taken place a 
series of remarkable changes commence in the uterus, which progress 
until the termination of pregnancy, and are well worthy of careful 
studv. They produce those marvellous modifications which effect the 
transformation of the small undeveloped uterus of the uon-pregnanl 
state into the large and folly developed uterus of pregnancy, and have 
no parallel in the whole animal economy. 



138 



PREGNANCY. 



A knowledge of theni is essential for the proper comprehension of 
the phenomena of labor, and for the diagnosis of pregnancy which the 
practitioner is so frequently called upon to make. Excluding the 
varieties of abnormal pregnancy, which will be noticed in another 
place, we shall here limit ourselves to the consideration of the modifi- 
cations of the maternal organism which result from simple and natural 
gestation. 

The unimpregnated uterus measures two and a half inches in length 
and weighs about one ounce, while at the full term of pregnancy it 
has so immensely grown as to weigh twenty-four ounces and measure 
twelve inches. The growth commences as soon as the ovum reaches 
the uterus, and continues uninterruptedly until delivery. In the early 
months the uterus is contained entirely in the cavity of the pelvis, and 
the increase of size is only apparent on vaginal examination, and that 
with difficulty. Before the third month the enlargement is chiefly in 

Fig. 73. 




Relations of the pregnant uterus at sixth month to the surrounding parts. 
(After Martin.) 

the lateral direction, so that the whole body of the uterus assumes 
more of a spherical shape than in the non-pregnant state. If an 
opportunity of examining the gravid uterus post mortem should occur 
at this time, it will be found to have the form of a sphere flattened 
somewhat posteriorly, and bulging anteriorly. 



PREGNANCY. 



139 



Fig. 74. 



A iter the ascent of' the organ into the abdomen it develops more In 
tlic vertical direction, so that at term it has the form of an ovoid, with 
its large extremity above and its narrow end at the cervix uteri, and 
its longitudinal axis corresponds to the long diameter of the mother's 
abdomen, provided the presentation be either of the head or breech. 
The anterior surface is now even more distinctly projecting than before 
— a fact which is explained by the proximity of the posterior surface 
to the rigid spinal column behind, while the anterior is in relation with 
the lax abdominal parictes, which yield readily to pressure, and so 
allow of the more marked prominence of the anterior uterine wall. 

Before the gravid uterus has risen out of the pelvis no appreciable 
increase in the si/e of the abdomen is perceptible. On the contrary, 
it is an old observation that at this early stage of pregnancy the 
abdomen is flatter than usual, on account of the partial descent of the 
uterus in the pelvic cavity as a result of its increased weight. As the 
growth of the organ advances, it soon becomes too large to be con- 
tained any longer within the pelvis, and about the middle of the third 
or the beginning of the fourth month the fundus rises above the pelvic 
brim — not suddenly, as is often erroneously thought, but slowly and 
gradually — when it may be felt as a smooth rounded swelling. 

It is about this time that the movements of the foetus first become 
appreciable to the mother, when "quickening" is said to have taken 

place. Toward the end of the fourth 
month the uterus reaches to about 
three fingers' breadth above the sym- 
physis pubis. About the fifth month 
it occupies the hypogastric region, to 
which it imparts a marked projection, 
and the alteration in the figure is now 
distinctly perceptible to visual exami- 
nation. About the sixth month it is 
on a level with, or a little above, the 
umbilicus (Fig. 73). About the sev- 
enth month it is about two inches 
above the umbilicus, which is now- 
projecting and prominent, instead of 
depressed, as in the non -pregnant 
state. During the eighth and ninth 
months it continues to increase until 
the summit of the fundus is imme- 
diately below the ensiform cartilage 
(Fig. 74). A more accurate estimate 
of the size of the uterine tumor at 
various periods of pregnancy can be 
obtained by measuring the distance 
between the fundus uteri and the upper margin of the symphysis pubis 
either with callipers or a measuring tape. The accompanying table gives 
the dimensions from the measurements of Spiegelberg 1 and Sutugin r 




Size of. uterus at various periods of 
pregnancy. 



i Lehrbuch der Geb.. Bd. ii. S. 11."). 

2 Obst. Journ. of Great Britain and Ireland, 1875, vol. iii. 



140 



PREGXANCY. 



Size of Uterus at Various Stages of Pregnancy. 





Week of 


pregnancy. 


Height of fundus uteri 
above pubes, measured 
by tape (Spiegelberg). 


Height of fundus uteri 
above pubes, measured 
by callipers (Sutugin). 


22d V 

24th y 






8.5 inches < 

10.5 
11.0 
11.5 
12.0 
12.5 
13.0 
13.2 


6 inches 
6.6 " 


26th j 
28th . 






7.3 

7.8 " 


30th . 






8.3 


32d ... .... 


8.7 


34th 


9.0 


36th ... 


9.3 


38th 


9.6 " 


40th 


10.0 



The former employed a tape measure, the latter used callipers, and 
his results are, therefore, more accurate. 

A knowledge of the size of the uterine tumor at various periods of 
pregnancy, as thus indicated, is of considerable practical importance, 
as forming the only guide by which we can estimate the probable 
period of delivery in certain cases in which the usual data for calcu- 
lation are absent, as, for example, when the patient has conceived 
during lactation. 

For about a week or more before labor the uterus generally sinks 
somewhat into the pelvic cavity, in consequence of the relaxation of 
the soft parts w hich precedes delivery, and the patient now feels her- 
self smaller and lighter than before. This change is familiar to all 
childbearing women, to whom it is known as " the lightening before 
labor." 

While the uterus remains in the pelvis its longitudinal axis varies 
in direction, much in the same way as that of the non-pregnant uterus, 
sometimes being more or less vertical, at others in a state of ante- 
version or partial retroversion. These variations are probably de- 
pendent on the distention or emptiness of the bladder, as its state 
must necessarily affect the position of the movable body poised behind 
it. After the uterus has risen into the abdomen, its tendency is to 
project forward against the abdominal wall, which forms its chief 
support in front. In the erect position the long axis of the uterine 
tumor corresponds with the axis of the pelvic brim, forming an angle 
of about 30° with the horizon. In the semi-recumbent position, on 
the other hand, as Duncan 1 has pointed out, its direction becomes 
much more nearly vertical. In women who have borne many chil- 
dren, the abdominal parietes no longer afford an efficient support, and 
the uterus is displaced anteriorly, the fundus in extreme cases even 
hanging; downward. 

In addition to this anterior obliquity, on account of the projection 
of the spinal column, the uterus is very generally also displaced lat- 
erally, and sometimes to a very marked degree, so that it may be felt 
entirely in one flank, instead of in the centre of the abdomen. In a 
large proportion of cases this lateral deviation is to the right side, and 

1 Researches in Obstetrics, p. 10. 



PRE G NANCY. Ill 

many hypotheses have beeD brought forward to explain tins fact, none 
of them being satisfactory. Thus, it has been supposed to depend on 
the greater frequency with which women lie on their right side during 
sleep, on the greater use of the right leg during walking, on the sup- 
posed comparative shortness of the right round ligament, which drags 
the tumor to that side, or on the frequent distention of the rectum on 
the left side, which prevents the uterus being displaced in that direc- 
tion. Of these the last is the cause which seems most constantly in 
operation, and most likely to produce the effect. 

The cervix must obviously adapt itself to the situation of the body 
of the uterus. We find, therefore, that in the early months, when the 
uterus lies low in the pelvis, it is more readily within reach. After 
the ascent of the uterus, it is drawn up, and frequently so much as to 
be reached with difficulty. When the uterus is much anteverted, as is 
so often the ease, the os is displaced backward, so that it cannot be felt 
at all by the examining finger. 

Toward the end of pregnancy the greater part of the anterior sur- 
face of the uterus is in contact with the abdominal wall, its lower 
portion resting on the posterior surface of the symphysis pubis. The 
posterior surface rests on the spinal column, while the small intestines 
are pushed to either side, the large intestines surrounding the uterus 
like an arch. 

Changes in the Uterine Parietes. — The great distention of the 
uterus during pregnancy was formerly supposed to be mainly due to 
the mechanical pressure of the enlarging ovum within it. If this 
were so, then the uterine walls w r ould be necessarily much thinner 
than in the non-pregnant state. This is well known not to be the 
case, and the immense increase in the size of the uterine cavity is to 
be explained by the hypertrophy of its walls. At the full period of 
pregnaucy the thickness of the uterine parietes is generally about the 
same as that of the non-pregnant uterus, rather more at the placental 
site, and less in the neighborhood of the cervix. Their thickness, 
however, varies in different places, and in some women they are so 
thin as to admit of the foetal limbs being very readily made out by 
palpation. Their density is, however, always much diminished, and, 
instead of being hard and inelastic, they become soft and yielding to 
pressure. This change coincides with the commencement of pregnancy, 
of which it forms, as recognizable in the cervix, one of the earliest 
diagnostic marks. At a more advanced period it is of value as admit- 
ting a certain amount of yielding of the uterine walls to movements 
of the foetus, thus lessening the chance of their being injured. Bandl 
has pointed out that during the latter months of pregnancy the lower 
segment of the uterus, to a distance of from four to six inches above 
the inner os, is thinner and less vascular than the tissues of the body 
of the uterus above. This thinner portion is separated from that above 
it by a ridge, often easily made out when the hand lias to be inserted 
into the uterus after delivery, known as " BandPs ring." 1 

1 Ueber das Verhaltea des Uterus und Cervix in der Schwangerscba ft and w&hrend der Geburt. 

1876. 



142 



PREGNANCY 



Changes in the Cervix during- Pregnancy. — Very erroneous 
views have long been taught, in most of our standard works on mid- 
wifery, as to the changes which occur in the cervix uteri during preg- 
nancy. It is generally stated that, as pregnancy advances, the cervical 
cavity is greatly diminished in length, in consequence of its being 
gradually drawn up so as to form part of the general cavity of the 
uterus, so that in the latter months it no longer exists. In almost all 



Fig. 75. 



Fig. 76. 








Fig. 77. 



Fig. 78. 





Supposed shortening of the cervix at the third, sixth, eighth, and ninth months of pregnancy, 
as figured in obstetric works. 

midwifery works accurate diagrams are given of this progressive short- 
ening of the cervix (Figs. 75 to 78). The cervix is generally described 
as having lost one-half of its length at the sixth month, two-thirds at 
the seventh, and to be entirely obliterated in the eighth and ninth. 
The correctness of these views was first called in question in recent 
times by Stoltz, in 1826, but Dr. Duncan, 1 in an elaborate historical 
paper on the subject, has shown that Stoltz was anticipated by Weit- 
brech in 1750, and to a less degree by Roederer and other writers. 
Their opinion is now pretty generally admitted to be correct, and is 
upheld by Cazeaux, Arthur Farre, Duncan, and most modern obste- 
tricians. Indeed, various post-mortem examinations in advanced preg- 
nancy have shown that the cavity of the cervix remains in reality of 
its normal length of one inch, and it can often be measured during 
life by the examining finger, on account of its patulous state (Fig. 79). 
During the fortnight immediately preceding delivery, however, a real 
shortening or obliteration of the cervical cavity takes place, com- 
mencing above, until the cervical canal is merged into the uterine 
cavity ; but this, as Duncan has pointed out, seems to be due to the 
incipient uterine contractions which prepare the cervix for labor. 



1 Researches in Obstetrics. 



V RE (J N A XCY 



1 13 



There is, no doubt, an apparent shortening of the oervfr always to 
be detected during pregnancy, bul this Isa fallacious and deceptive 
feeling, due to the softness of the tissue of the cervix, \\ bich is exceed- 
ingly characteristic of pregnancy, and which to an experienced finger 

affords one of its best diagnostic marks. 



Fig. 79. 




Cervix from a woman dying in the eighth month of pregnancy. (After Duncan.) 



In the non-pregnant state the tissue of the cervix is hard, firm, and 
inelastic. "When conception occurs, softening begins at the external 
os, and proceeds gradually and slowly upward until it involves the 
whole of the cervix. It results from serous infiltration of the tissues, 
associated with passive dilatation of the vessels. By the end of the 
fourth month both lips of the os are thick, softened, and velvety to 
the touch, giving a sensation likened by Cazeaux to that produced by 
pressing on a table through a thick, soft cover. By the sixth month 
at least one-half of the cervix is thus altered, and by the eighth the 
whole of it, and so much so that at this time those unaccustomed to 
vaginal examination experience some difficulty in distinguishing it 
from the vaginal walls. It is this softening, then, which give- rise to 
the apparent shortening of the cervix so generally described, and it is 
an invariable concomitant of pregnancy, except in some rare cases in 
which there has been antecedent morbid induration and hypertrophic 
elongation of the cervix. If, therefore, on examining a woman sup- 
posed to be advanced in pregnancy, we find the cervix to be hard and 
projecting into the vaginal canal, we may safely conclude that preg- 
nancy does not exist. The existence of softening, however, it must be 
remembered, will not itself justify an opposite conclusion, as it may 



144 PREGNANCY. 

be produced, to a very considerable extent, by various pathological 
conditions of the uterus. 

At the same time that the tissue of the cervix is softened, its cavity 
is widened, and the external os becomes patulous. This change varies 
considerably in primiparae and multipara?. In the former the external 
os often remains closed until the end of pregnancy ; but even in them 
it generally becomes more or less patulous after the seventh month, 
and admits the tip of the examining finger. In women who have 
.borne children this change is much more marked. The lips of the 
^external os are in them generally fissured and irregular, from slight 
lacerations of its tissue in former labors. It is also sufficiently open 
to admit the tip of the finger, so that in the latter months of preg- 
nancy it is often quite possible to touch the membranes, and through 
them to feel the presenting part of the child. 

The remarkable increase in size of the uterus during pregnancy is, 
as we have seen, chiefly to be explained by the growth of its struc- 
tures, all of which are modified during gestation. The peritoneal 
covering is considerably increased, so as still to form a complete cover- 
ing to the uterus when at its largest size. William Hunter supposed 
that its extension was effected rather by the unfolding of the layers of 
the broad ligament than by growth. That the layers of the broad 
ligament do unfold during gestation, especially in the early months, is 
probable ; but this is not sufficient to account for the complete invest- 
ment of the uterus, and it is certain that the peritoneum grows pari 
passu with the enlargement of the uterus. In addition, there is a 
new formation of fibrous tissue between the peritoneal and the mus- 
cular coats, which affords strength, and diminishes the risk of lacera- 
tion during labor. 

The hypertrophy of the muscular tissue of the uterus is, however, 
the most remarkable of the changes produced by pregnancy. Isot 
only do the previously existing rudimentary fibre-cells become enor- 
mously increased in size — so as to measure, according to Kolliker, 
from seven to eleven times their former length, and from two to five 
times their former breadth — but new unstriped fibres are largely 
developed, especially in the inner layers. These new cells are chiefly 
found in the first months of pregnancy, and their growth seems to be 
completed by the sixth month. The connective tissue between the 
muscular layers is also largely increased in amount. The weight of 
the muscular tissue of the gravid uterus is, therefore, much increased, 
and it has been estimated by Heschl that it weighs at term from 1 to 
1.5 lb., that is, about sixteen times more than in the unimpregnated 
state. This great development of the muscular tissue admits of its 
dissection in a way which is quite impossible in the unimpregnated 
state, and the researches of Helie (p. 62) enable us to understand much 
better than before how the muscles forming the walls of the gravid 
uterus act during the expulsion of the child. 

The changes in the mucous coat of the uterus which result in the 
formation of the decidua have already been discussed at length 
elsewhere (p. 102). 

The circulatory apparatus of the uterus during pregnancy has been 



PRKi; N a\i'v. 1 10 

described when the anatomy of the placenta was under consideration 
(p. 115). 

rhe lymphatics are much Increased in size; and recent theories on 
the production of certain puerperal diseases attribute to them a more 

important action than has been commonly assigned to them. 

The question of the growth of the nerves has been hotly discussed. 
Robert Lee took the foremost place among those who maintained that 
the nerves of the uterus share the general growth of it- other con- 
stituent parts. Dr. Snow Beck, however, believed thai they remain 
of the same size as in the unimpregnated state, and this view is sup- 
ported by Hirschfeld, Robin, and other recent writers. Robin thought 
that there is an apparent increase in the size of the nerve-tubes, 
which, however, is really due to increase in the neurilemma. Kilian 
describes the nerves as increasing- in length but not in thickness, 
while Schroeder states that they participate equally with the lym- 
phatics in the enlargement the latter undergo. Whichever of these 
views may ultimately be found to be correct, it is certain that analogy 
would lead us to expect an increase of nervous as well as of vascular 
supply. 

General Modifications in the Body produced by Pregnancy. — 
It is not in the uterus alone that pregnancy is found to produce modi- 
fications of importance. There are few of the more important functions 
of the body which are not, to a greater or less extent, affected ; to 
some of these it is necessary briefly to direct attention, inasmuch as, 
when carried to excess, they produce those disorders which often com- 
plicate gestation, and which prove so distressing and even dangerous 
to the patients. Such of them as are apparent and may aid us in 
diagnosis are discussed in the chapter which treats of the signs and 
symptoms of pregnancy ; in this place it is only necessary to refer to 
those w r hich do not properly fall into that category. 

Amongst those which are most constant and important are the 
alterations in the composition of the blood. The opinion of the pro- 
fession on this subject has, of late years, undergone a remarkable 
change. Formerly it was universally believed that pregnancy was, 
as the rule, associated with a condition analogous to plethora, and 
that this explained many characteristic phenomena of common occur- 
rence, such as headache, palpitation, singing in the ears, shortness of 
breath, and the like. As a consequence it was the habitual custom, 
not yet bv any means entirely abandoned, to treat pregnant women on 
an antiphlogistic system ; to place them on low diet, to administer 
lowering remedies, and very often to practise venesection, sometimes 
to a surprising extent. Thus it was by no means rare for women to 
be bled six or eight times during the latter months, even when no 
definite symptoms of disease existed; and many of the older authors 
record cases where depletion was practised every fortnight as a matter 
of routine, and, when the symptoms were well marked, even from 
fifty to ninety times in the course of a single pregnancy. 

Composition of the Blood in Pregnancy. — Numerous careful 
analyses have conclusively proved that the composition of the blood 
during pregnancy is very generally — perhaps it would not be too 

10 



146 PREGNANCY. 

much to say always — profoundly altered. To meet the necessities of 
the largely increased vascular arrangements of the uterus, the total 
amount of blood in the system is increased. 1 It is found to be more 
watery, its serum is deficient in albumin, and the amount of colored 
globules is materially diminished, averaging, according to the analysis 
of Becquerel and Roclier, 111.8 against 127.2 in the non-gravid state. 
At the same time the amount of fibrin and of extractive matter is 
considerably increased. The latter observation is of peculiar impor- 
tance, and it goes far to explain the frequency of certain thrombotic 
affections observed in connection with pregnancy and delivery ; this 
hyperinosis of the blood is also considerably increased after labor by 
the quantity of effete material thrown into the mother's system at that 
time, to be got rid of by her emunctories. The truth is, that the 
blood of the pregnant woman is generally in a state much more nearly 
approaching the condition of anaemia than of plethora, and it is certain 
that most of the phenomena attributed to plethora may be explained 
equally well and better on this view. These changes are much more 
strongly marked at the latter end of pregnancy than at its commence- 
ment, and it is interesting to observe that it is then that the concomi- 
tant phenomena alluded to are most frequently met with. Cazeaux, 
to whom Ave are chiefly indebted for insisting on the practical bearing 
of these views, contends that the pregnant state is essentially analogous 
to chlorosis, and that it should be so treated. More recently the 
accurate observations of Willcocks 1 have shown that the blood of 
pregnancy differs from that of chlorosis in the fact that while in both 
the amount of haemoglobin is lessened, in pregnancy the individual 
blood-cells are not impoverished as they are in chlorosis, but simply 
lessened in comparative number, owing to an increase in the water of 
the plasma, due to the progressive enlargement of the vascular area 
during gestation. Objection has not unnaturally been taken to 
Cazeaux's theory, as implying that a healthy and normal function is 
associated with a morbid state, and it has been suggested that this de- 
teriorated state of the blood may be a wise provision of Nature instituted 
for a purpose we are not as yet able to understand. It may certainly 
be admitted that pregnancy, in a perfectly healthy state of the system, 
should not be associated with phenomena in themselves in any degree 
morbid. It must not be forgotten, however, that our patients are 
seldom — we might safely say never — in a state that is physiologically 
healthy. The influence of civilization, climate, occupation, diet, and 
a thousand other disturbing causes that, to a greater or less degree, 
are always to be met with, must not be left out of consideration. 
Making every allowance, therefore, for the undoubted fact that preg- 
nancy ought to be a perfectly healthy condition, it must be conceded, 
I think, that in the vast majority of cases coming under our notice it 
is not entirely so ; and the deductions drawn by Cazeaux, from the 
numerous analyses of the blood of pregnant women, seem to point 
strongly to the conclusion that the general blood-state is tending to 

i Arch. f. Gynak., 1872, Bd. iv. S. 112. 

2 "Comparative Observations on the Blood in Chlorosis and Pregnancy," by Fred. Willcocks, 
M.D., The Lancet, December 3, 1881. 



P R EG N A N'CY. 117 

poverty and ansemia, and that a depressing and antiphlogistic treatment 
is distinctly contra-indicated. 

Modifications in certain Viscera. — Closely connected w it h the 
altered condition of the blood is the physiological hypertrophy of the 
heart, which is now well known to occur during pregnancy. This 
was first pointed out byLarcher in 1828, and it has been since verified 
by numerous observers. It seems to be constant and considerable, 
and to be a purely physiological alteration intended to meet the 
increased exigencies of the circulation which the complex vascular 
arrangements of the gravid uterus produce. The hypertrophy is 
limited to the left ventricle; the right ventricle, as well as both 
auricles, being unaffected. Blot estimates that the whole weight of 
the heart increases one-fifth during gestation. The more recenl re- 
seaches of Lohlein 1 render it probable that the hypertrophy is less 
than those authors have supposed. According to Duroziez 2 the heart 
remains enlarged during lactation, but diminishes in size immediately 
after delivery in women who do not suckle, while in women who have 
borne many children it remains permanently somewhat larger than in 
nullipara?. Similar increase in the size of other organs has been pointed 
out by various writers, as, for example, in the lymphatics, the spleen, 
and the liver. Tarnier states that in women who have died after 
delivery, the organs always show signs of tatty degeneration. Accord- 
ing to Gassner, the wdiole body increases in weight during the latter 
months of pregnancy, and this increase is somewhat beyond that which 
can be explained by the size of the womb and its contents. 

Formation of Osteophytes. — Irregular bony deposits between the 
skull and the dura mater, in some cases so largely developed as to line 
the whole cranium, have been so frequently detected in women who 
have died during parturition that they are believed by some to be a 
normal production connected with pregnancy. Ducrest found these 
osteophytes in more than one-third of the cases in which he performed 
post-mortem examinations during the puerperal period. Rokitansky, 
who corroborated the observation, believed this peculiar deposit of 
bony matter to be a physiological, and not a pathological, condition 
connected with pregnancy; but whether it be so, or how it is produced, 
has not yet been satisfactorily determined. 

Changes in the Nervous System. — More or less marked changes 
connected with the nervous system are generally observed iu pregnancy, 
and sometimes to a very great extent. When carried to excess they 
produce some of the most troublesome disorders which complicate 
gestation, such as alterations in the intellectual functions, changes iu 
the disposition and character, morbid cravings, dizziness, neuralgia, 
syncope, and many others. They are purely functional in their char- 
acter, and disappear rapidly after delivery, and may be best described 
in connection with the disorders of pregnancy. 

Changes in the Respiratory Organs. — Respiration is often in- 
terfered with, from the mechanical results of the pressure of the 

1 ZeitschriftflirGeburtshiilfe und Gynak., 1876, Bd. i. S. 482, " Ueberdas Verhalten des Hcrzeus 
bei Schwangeren u. Wiichneriimen." 

2 Gaz. des Hupit, 1868. 



148 PKEGNANCY. 

enlarged uterus. The longitudinal dimensions of the thorax are 
lessened by the upward displacement of the diaphragm, and this 
necessarily leads to some embarrassment of the respiration, which is, 
however, compensated, to a great extent, by an increase in breadth of 
the base of the thoracic cavity. 

Changes in the Liver. — The liver has been observed to show 
certain changes in pregnancy. Numerous small yellow spots are seen 
scattered through its substance, varying in size from a pin's head to a 
millet-seed, and these are produced by fatty deposits in the hepatic 
cells, which De Sinety believes to be associated mainly with lactation, 
and to disappear when that is concluded. 

Changes in the Urine. — Certain changes, which are of very con- 
stant occurrence, in the urine of pregnant wonien have attracted much 
attention, and have been considered by many writers to be pathogno- 
monic. They consist in the presence of a peculiar deposit, formed 
when the urine has been allowed to stand for some time, which has 
received the name of kiestein. Its presence was known to the ancients, 
and it was particularly mentioned by Savonarola in the fifteenth cen- 
tury, but it has more especially been studied within the last thirty 
years by Eguisier, Golding Bird, and others. If the urine of a preg- 
nant woman be allowed to stand in a cylindrical vessel, exposed to 
light and air, but protected from dust, in a period varying from two 
to seven days, a peculiar flocculent sediment, like fine cotton-wool, 
makes its appearance in the centre of the fluid, and soon afterward 
rises to the surface and forms a pellicle, which has been compared to 
the fat of cold mutton-broth. In the course of a few days the scum 
breaks up and falls to the bottom of the vessel. On microscopic 
examination it is found to be composed of fat particles, with crystals 
of ammoniaco-magnesium phosphates and phosphate of lime, and a 
large quantity of vibriones. These appearances are generally to be 
detected after the second month of pregnancy, and up to the seventh 
or eighth month, after which they are rarely produced. Regnauld 
explains their absence during the latter months of gestation by the 
presence in the urine, at that time, of free lactic acid, which increases 
its acidity, and prevents the decomposition of the urea into carbonate 
of ammonia. He believes that kiestein is produced by the action of 
free carbonate of ammonia on the phosphate of lime contained in the 
urine, and that this reaction is prevented by the excess of acid. 

Golding Bird believed kiestein to be analogous to casein, to the 
presence of which he referred it, and he states that he has found it in 
twenty-seven out of thirty cases. Braxton Hicks so far corroborates 
this view, and states that the deposit of kiestein can be much more 
abundantly produced if one or two teaspoonfuls of rennet be added to 
the urine, since that substance has the property of coagulating casein. 
Much less importance, however, is now attached to the presence of 
kiestein than formerly, since a precisely similar substance is sometimes 
found in the urine of the non-pregnant, especially in anaemic women, 
and even in the urine of men. Parkes states that it is not of uniform 
composition, that it is produced by the decomposition of urea, and 
consists of the free phosphates, bladder mucus, infusoria, and vaginal 



SIGNS AND SYMPTOMS OF PREGNANCY. 11!") 

discharges. Neugebauer and Vogel give a similar aoeounl of it, and 
hold that it is of qo diagnostic value. That it is of interest as indi- 
cating the changes going od in connection with pregnancy, is certain; 
but inasmuch as it is not of invariable occurrence, and may even exisl 
quite independently of gestation, it is obviously quite undeserving of 
the extreme importance that has been attached to it. 

Toward the end of pregnancy sugar may sometimes be detected in 
the urine, and after delivery and during lactation it exists in consider- 
able abundance; thus, out of thirty-five cases tested in the Simpson 
Memorial Hospital in Edinburgh during the puerperium, it Mas found 
in all, the amount varying from 1 to 8 per cent. 1 Kaltenbach has 
shown that this temporary glycosuria is due to the presence of milk- 
sugar in the urine, and that it ceases with the disappearance of milk 
from tlie breasts. 2 This physiological glycosuria must be carefully 
distinguished from true diabetes, which is a grave complication of 
pregnancy. 

Albumin is often present during the latter stages of pregnancy, and 
it may be transitory and of comparatively little moment, although its 
presence must always be a cause of some anxiety. Ley den believes 
that it is most often met with in the second half of a first pregnancy, 
and it may become chronic, leading to granular atrophy of the kid- 
neys. 3 In some cases it seems to be the result of catarrhal conditions 
of the bladder, in others it is probably caused by undue arterial 
tension consequent on pregnancy. 



CHAPTEE IV. 

SIGNS AXD SYMPTOMS OF PREGNANCY. 

In attempting to ascertain the presence or absence of pregnancy, the 
practitioner has before him a problem which is often beset with great 
difficulties, and on the proper solution of which the moral character 
of his patient, as well as his own professional reputation, may depend. 
The patient and her friends can hardly be expected to appreciate the 
fact that it is often far from easy to give a positive opinion on the 
point; and it is always advisable to use much caution in the examina- 
tion, and not to commit ourselves to a positive opinion, except on the 
most certain grounds. This is all the more important because it is 
just in those cases in which our opinion is most frequently asked that 
the statements of the patient are of least value, as she is either 

i Edin. Med. Journ., vol. 1**1-82. p. 116. . 

a Zeit. f. Geburt. u. Gvn.. 1879, B<1. iv. p. 161, "Die Lactosune der Wuchnennnen." 

3 Deutsche med. Wochenschr.. 1886, No. y. 



150 PREGNANCY. 

anxious to conceal the existence of pregnancy, or, if desirous of an 
affirmative diagnosis, unconsciously colors her statements so as to bias 
the judgment of the examiner. 

Classification. — Constant attempts have been made to classify the 
signs of pregnancy ; thus some divide them into the natural and 
sensible signs, others into the presumptive, the probable, and the certain. 
The latter classification, which is that adopted by Montgomery in his 
classical work on the Signs and Symptoms of Pregnancy, is no doubt 
the better of the two, if any be required. The simplest way of 
studying the subject, however, is the one, now generally adopted, of 
considering the signs of pregnancy in the order in which they occur, 
aud attaching to each an estimate of its diagnostic value. 

Signs of a Fruitful Conception. — From the earliest ages authors 
have thought that the occurrence of conception might be ascertained 
by certain obscure signs, such as a peculiar appearance of the eyes, 
swelling of the neck, or by unusual sensations connected with a 
fruitful intercourse. All of these, it need hardly be said, are far too 
uncertain to be of the slightest value. The last is a symptom on which 
many married women profess themselves able to depend, and one to 
which Cazeaux is inclined to attach some importance. 

The first appreciable indication of pregnancy on which any depend- 
ence can be placed is the cessation of the customary menstrual dis- 
charge, and it is of great importance, as forming the only reliable 
guide for calculating the probable period of delivery. In women who 
have been previously perfectly regular, in whom there is no morbid 
cause which is likely to have produced suppression, the non-appearance 
of the catamenia may be taken as strong presumptive evidence of the 
existence of pregnancy; but it can never be more than this, unless 
verified and strengthened by other signs, inasmuch as there are many 
conditions besides pregnancy which may lead to its non-appearance. 
Thus exposure to cold, mental emotion, general debility, especially 
Avhen connected with incipient phthisis, may all have this effect. 
Mental impressions are peculiarly liable to mislead in this respect. 
It is far from uncommon in newly-married women to find that men- 
struation ceases for one or more periods, either from the general dis- 
turbance of the system connected with the married life, or from a 
desire on the part of the patient to find herself pregnant. Also in 
unmarried women who have subjected themselves to the risk of 
impregnation, mental emotion and alarm often produce the same 
result. 

A further source of uncertainty exists in the fact that in certain 
cases menstruation may go on for one or more periods after conception, 
or even during the whole pregnancy. The latter occurrence is cer- 
tainly of extreme rarity, but one or two instances are recorded bv 
Perfect, Churchill, and other writers of authority, and therefore its 
possibility must be admitted. The former is much less uncommon, 
and instances of it have probably come under the observation of most 
practitioners. The explanation is now well understood. During the 
early months of gestation, when the ovum is not yet sufficieutlv 
advanced in growth to fill the whole uterine cavity, there is a consider- 



SIGNS AND SYMPTOMS OF PREGNANCY. L6] 

able space between the decidua reflexa which surrounds it and the 
decidua vera lining the uterine cavity. It is from this free -urine, of 
die decidua vera that the periodica] discharge comes, and there is nol 

only ample surface for it to come from, hut a free channel for its 
escape through the os uteri. After the third month thedecidua reflexa 

and the decidua vera Mend together, and the space between them dis- 
appears. Menstruation after this time is, therefore, much more diffi- 
cult to account for. It is probable that, in many supposed cases, 
occasional losses of blood from other sources, such as placenta previa, 
an abraded cervix uteri, or a small polypus, have been mistaken for 
true menstruation. If the discharge really occurs periodically after 
the third mouth, it cau only come from the canal of the cervix.' The 
occurrence, however, is so rare, that if a woman is menstruating 
regularly and normally who believes herself to be more than four 
months advanced in pregnancy, Ave are justified ipso facto in negativing 
her supposition. In an unmarried woman all statements as to regu- 
larity of menstruation are absolutely valueless, for in such cases 
nothing is more common than for the patient to make false statements 
for the express purpose of deception. 

Conception may unquestionably occur when menstruation is nor- 
mally absent. This is far from uncommon in women during lactation, 
when the function is in abeyance, and who therefore have no reliable 
data for calculating the true period of their delivery. Authentic cases 
are also recorded in which young girls have conceived before men- 
struation is established, and in which pregnancy has occurred after 
the change of life. 

Taking all these facts into account, we can only look upon the 
cessation of menstruation as a fairly presumptive sign of pregnancy in 
women in whom there is no clear reason to account for it, but one 
which is undoubtedly of great value in assisting our diagnosis. 

Shortly after conception various sympathetic disturbances of the 
system occur, and it is only very exceptionally that these are not 
established. They are generally most developed in women of highly 
nervous temperament ; and they are, therefore, most marked in patients 
in the upper classes of society, in whom this class of organization is 
most common. 

Morning- Sickness. — Amongst the most frequent of these are vari- 
ous disorders of the gastro-intestinal canal. Nausea or vomiting is very 
common ; and as it is generally felt on first rising from the recumbent 
position, it is commonly known amongst women as the " morning 
sickness." It sometimes commences almost immediately after concep- 
tion, but more frequently not until the second month, and it rarely 
lasts after the fourth month. Generally there is nausea rather than 
actual vomiting. The woman feels sick and unable to eat her break- 
fast, and often brings up some glairy fluid. In other cases she actually 
vomits; and. sometimes the sickness is so excessive as to resisl all 
treatment, seriously to affect the patient's health, and even imperil 
her life. These grave forms of the affection will require separate 
consideration. 

Very different opinions have been held as to the cause of morning 



152 PREGNANCY. 

sickness. Dr. Henry Bennet believes that, when at all severe, it is 
always associated with congestion and inflammation of the cervix uteri. 
Dr. Graily Hewitt maintains that it depends entirely on flexion of 
the uterus producing irritation of the uterine nerves at the seat of the 
flexion, and consequent sympathetic vomiting. This theory, when 
broached at the Obstetrical Society, was received with little favor ; it 
seems to me to be sufficiently disproved by the fact, which I believe 
to be certain, that more or less nausea is a normal and nearly constant 
phenomenon in pregnancy ; for it is difficult to believe that nearly 
every pregnant woman has a flexed uterus. The generally received 
explanation is probably the correct one, viz., that nausea, as well as 
other forms of sympathetic disturbance, depend on the stretching of 
the uterine fibres, by the growing ovum, and consequent irritation of 
the uterine nerves. It is, therefore, one, and only one, of the numer- 
ous reflex phenomena naturally accompanying pregnancy. It is an 
old observation that when the sickness of pregnancy is entirely 
absent, other, and generally more distressing, sympathetic derange- 
ments are often met with, such as a tendency to syncope. Dr. 
Bedford 1 has laid especial stress on this point, and maintains that 
under such circumstances women are peculiarly apt to miscarry. 

Other derangements of the digestive functions, depending on the 
same cause, are not uncommon, such as excessive or depraved appetite, 
the patient showing a craving for strange and even disgusting articles 
of diet. These cravings may be altogether irresistible, and are popu- 
larly known as " longings." Of a similar character is the disturbed 
condition of the bowels frequently observed, leading to constipation, 
diarrhoea, and excessive flatulence. 

Certain glandular sympathies may be developed, one of the most 
common being an excessive secretion from the salivary glands. A 
tendency to syncope is not unfrequent, rarely proceding to actual 
fainting, but rather to that sort of j>artial syncope, unattended with 
complete loss of consciousness, which the older authors used to call 
" leipothymia." This often occurs in women who show no such 
tendencv at other times, and, when developed to any extent, it forms 
a very distressing accompaniment of pregnancy. Toothache is com- 
mon, and is not rarely associated with actual caries of the teeth. 
When any of these phenomena are carried to excess it is more than 
probable that some morbid condition of the uterus exists, which 
increases the local irritation producing them. 

Mental Peculiarities. — Mental phenomena are very general. An 
undue degree of despondency, utterly beyond the patient's control, is 
far from uncommon ; or a change which renders the bright and good- 
tempered woman fractious and irritable ; or even the more fortunate, 
but less common, change, by which a disagreeable disposition becomes 
altered for the better. 

All these phenomena of exalted nervous susceptibility are but of 
slight diagnostic value. They may be taken as corroborating more 
certain signs, but nothing more ; and they are chiefly interesting 

1 Diseases of Women and Children, p. 551. 



SIGNS AND SYMPTOMS OF PREGNANCY. L58 

from their tendency to be carried to excess and to produce serious 

disorders. 

Certain changes in the mamma' are of carls occurrence, dependent, 
no doubt, on the intimate sympathetic relations at all times existing 
between them and the uterine organs, bul chiefly required for the 
purpose of preparing for the important function of lactation, which, 
on the termination of pregnancy, they have to perform. 

Generally about the second month of pregnancy the breasts become 
increased in size, and tender. As pregnancy advances they become 
much larger and tinner, the enlargement being caused by growth both 
of connective and glandular tissue, and bine veins may be seen cours- 
ing over them. The most characteristic changes are about the nipples 
and areolae. The nipples become turgid, and are frequently covered 



Fig. SO. 






y 



Appearance of the areola in pregnancy. 

with minute branny scales, formed by the desiccation of sero-lactc^vni 
fluid oozing from "them. The areolae become greatly enlarged and 
darkened from the deposit of pigment (Fig. 80). The extent and 
degree of this discoloration vary much in different women. In fair 
women it may be so slight as to 'be hardly appreciable; while in dark 
women it is generally exceedingly characteristic, sometimes forming a 
nearly black circle extending over a great partof the; breast. The areola 
becomes moist as well as dark in appearance, is somewhat swollen, 
and a number of small tubercles are developed upon it, forming a 
circle of projections round the nipple. These tubercles are described 
by Montgomery as being intimately connected with the lactiferous 
ducts, some of which may occasionally be traced into them and seem 
to open on their summits. As pregnancy advances they increase in 
size and number. During the latter months what has been called 



154 PEEGXANCY. 

u the secondary areola " is produced, and when well marked presents 
a very characteristic appearance. It consists of a number of minute 
discolored spots all round the outer margin of the areola where the 
pigmentation is fainter, and which are generally described as resem- 
bling spots from which the color has been discharged by a shower of 
water-drops. This change, like the darkening of the primary areola, 
is more marked in brunettes. At this period, especially in women 
whose skin is of fine texture, whitish silvery streaks are often seen on 
the breasts. They are produced by the stretching of the cutis vera, 
and are permanent. 

By pressure on the breasts a small drop of serous-looking fluid can 
very generally be forced out from the nipple, often as early as the 
third month, and on microscopic examination milk and colostrum 
globules can be seen in it. 

The diagnostic value of these mammary changes has been variously 
estimated. When well marked they are considered by Montgomery 
to be certain signs of pregnancy. To this statement, however, some 
important limitations must be made. In women who have never 
borne children they, no doubt, are so ; for, although various uterine 
and ovarian diseases produce some darkening of the areola, they cer- 
tainly never produce the well-marked changes above described. In 
multipara, however, the areola? often remain permanently darkened, 
and in them these signs are much less reliable. In first pregnancies 
the presence of milk in the breasts may be considered an almost cer- 
tain sign, and it is one which I have rarely failed to detect even from 
a comparatively early period. It is true that there are authenticated 
instances of non-pregnant women having an abundant secretion of 
milk established from mammary irritation. Thus Baudelocque pre- 
sented to the Academy of Surgery of Paris a young girl, eight years 
of age, who had nursed her little brother for more than a month. 
Dr. Tanner states — I do not know on what authority — that " it is not 
uncommon in Western Africa for young girls who have never been 
pregnant to regularly employ themselves in nursing the children of 
others, the mammae being excited to action by the application of the 
juice of one of the Euphorbiaceae." Lacteal secretion has even been 
noticed in the male breast. But these exceptions to the general rule 
are so uncommon as merely to deserve mention as curiosities ; and I 
have hardly ever been deceived in diagnosing a first pregnancy from 
the presence of even the minutest quantity of lacteal secretion in the 
breasts, although even then other corroborative signs should always 
be sought for. In multipara the presence of milk is by no means so 
valuable, for it is common for milk to remain in the mammae long 
after the cessation of lactation, even for several years. Tyler Smith 
correctly says that " suppression of the milk in persons who are 
nursing and liable to impregnation is a more valuable sign of preg- 
nancy than the converse condition." This is an observation I have 
frequently corroborated. 

As a diagnostic sign, therefore, the mammary appearances are of 
great importance in primiparae, and when well marked they are seldom 
likely to deceive. They are specially important when we suspect 



SIGNS AND symptoms OP PREGNANCY. 155 

pregnancy in the unmarried, as we can easily make an excuse to look 
at the breast without explaining t<> the patient the reason ; and a 
single glance, especially it' the patient be dark-complexioned, maj 
so Far strengthen our suspicion as to justify a more thorough examina- 
tion. In married multipara' they arc less to be depended upon. 

In connection with this subject may be mentioned various irregular 
deposits of pigment which are frequently observed. The most com- 
mon is a dark-brownish or yellowish line starting from the pubes and 
running up the centre of the abdomen, sometimes as far as the um- 
bilicus only, at others forming an irregular ring around the umbilicus, 
and reaching to the epigastrium. It is, however, of very uncertain 
occurrence, being well marked in some women, while in others it is 
entirely absent. ['] Patches of darkened skin are often observed about 
the face, chiefly on the forehead, and this bronzing sometimes gives a 
very peculiar appearance. Joulin states that it only occurs on parts 
of the face exposed to the sun, and that it is therefore mosl fre- 
quently observed in women of the lower orders who are freely exposed 
to atmospheric influences. These pigmentary changes are of small 
diagnostic value, and may continue for a considerable time after de- 
livery. 

The progressive enlargement of the abdomen, and the size of the 
gravid uterus at various periods of pregnancy, as well as the method 
of examination by means of abdominal palpation, have alreadv been 
described (pp. 129 and 137-140). 

Foetal Movements. — We will now consider the well-known phe- 
nomena produced by the movements of the foetus in utero, which arc 
so familiar to all pregnant women. These, no doubt, take place from 
the earliest period of foetal life at which the muscular tissue of the 
foetus is sufficiently developed to admit of contraction, but they are 
not felt by the mother until somewhere about the sixteenth week of 
utero-gestation, the precise period at which they are perceived varying 
considerably in different cases. The error of the law on this subject, 
which supposes the child not to be alive, or "quick," until the mother 
feels its movements, is well known, and has frequently been protested 
against by the medical profession. The so-called quickening — which 
certainlv is felt very suddenly by some women — is believed to depend 
on the rising of the uterine tumor sufficiently high to permit of the 
impulse of the foetus being transmitted to the maternal abdominal walls, 
through the sensory nerves of which its movements become appreci- 
able. The sensation is generally described as being a feeble flutter- 
ing, which, when first felt, not unfrequently causes unpleasant 
nervous sensations. As the uterus enlarges, the movements become 
more and more distinct, and generally consist of a series of sharp 
blows or kicks, sometimes quite appreciable to the naked eye, and 
causing distinct projections of the abdominal walls. Their force and 
frequencv will also vary during pregnancy according to circumstances. 
At times they are very frequent and distressing; at others, the foetus 

P The color-line is particularly well marked in the African race, and is very black in the full- 
blooded negro. In tumor cases, there is often a well-defined line over the linen alba, winch is 
sometimes quite crooked, and of an orange hue.— En. J 



156 PREGNANCY 

seems to be comparatively quiet, and they may even not be felt for 
several days in succession, and thus unnecessary fears as to death 
of the foetus often arise. The state of the mother's health has an 
undoubted influence upon them. They are said to increase in force 
after a prolonged abstinence from food, or in certain positions of the 
body. It is certain that causes interfering with the vitality of the 
foetus often produce very irregular and tumultuous movements. They 
can be very readily felt by the accoucheur on palpating the abdomen, 
and sometimes, in the latter months, so distinctly as to leave no doubt 
as to the existence of pregnancy. They can also generally be induced 
by placing one hand on each side of the abdomen and applying 
gentle pressure, which will induce foetal motion that can be easily 
appreciated. 

As a diagnostic sign the existence of foetal movements has always 
held a high place, but care should be taken in relying on it. It is 
certain that wonien are themselves very often in error, and fancy they 
feel the movements of a foetus when none exists, being probably 
deceived by irregular contractions of the abdominal muscles, or by 
flatus within the bowels. They may even involuntarily produce such 
intra-abdominal movements as may readily deceive the practitioner. 
Of course, in advanced pregnancy, when the foetal movements are so 
marked as to be seen as well as felt, a mistake is hardly possible, and 
they then constitute a certain sign. But in such cases there is an 
abundance of other indications and little room for doubt. In ques- 
tionable cases, and at an early period of pregnancy, the fact that move- 
ments are not felt must not be taken as a proof of the non-existence 
of pregnancy, for they may be so feeble as not to be perceptible, or 
they may be absent for a considerable period. 

Braxton Hicks L has directed attention to the value, from a diagnostic 
point of view, of intermittent contractions of the uterus during preg- 
nancy. After the uterus is sufficiently large to be felt by palpation, 
if the hand be placed over it, and it be grasped for a time without 
using any friction or pressure, it will be observed to distinctly harden 
in a manner that is quite characteristic. This intermittent contraction 
occurs every five or ten minutes, sometimes oftener, rarely at longer 
intervals. The fact that the uterus does contract in this way had been 
previously described, more especially by Tyler Suiith, Avho ascribed it 
to peristaltic action. But it is certain that no one, before Dr. Hicks, 
had pointed out the fact that such contractions are constant and 
normal concomitants of pregnancy, continuing during the whole 
period of utero-gestation, and forming a ready and reliable means of 
distinguishing the uterine tumor from other abdominal enlargements. 
Since reading Dr. Hicks's paper I have paid considerable attention to 
this sign, which I have never failed to detect, even in the retroverted 
gravid uterus contained entirely in the pelvic cavity, and I am dis- 
posed entirely to agree with him as to its great value in diagnosis. If 
the hand be kept steadily on the uterus, its alternate hardening and 
relaxation can be appreciated with the greatest ease. The advantages 

i Obst. Trans., 1S72, vol. xiii. p. 216. 



SIGNS AND SYMPTOMS OP PREGNANCY. 157 

which this Bign has over the fetal movements are thai it is constant, 
that it is not Liable to be simulated by anything else, and thai it is 
independent of the life of the child, being equally appreciable when 
the uterus contains a degenerated ovum or deaa fetus. The only con- 
dition likely to give rise to error is an enlargement of the uterus In 
consequence of contents other than the results of conception, such as 
retained menses, or a polypus. The history of such caa — n hich are, 
moreover, of extreme rarity — would easily prevent any mistake. As 
a corroborative sign of pregnancy, therefore, I should give these in- 
termittent contractions a high place. [ l ] 

The vaginal signs of pregnancy are of considerable importance 
in diagnosis. They are chiefly the changes which may be detected in 
the cervix, and the so-called bo'llottement, which depends nn the mobility 
of the foetus in the liquor amnii. 

Softening of the Cervix. — The alterations in the density and 
apparent length of the cervix have been already described (p.* 142). 
When pregnancy has advanced beyond the fifth month the peculiar 
velvety softness of the cervix is very characteristic, and affords a strong 
corroborative sign, but one which it would be unsafe to rely on bv 
itself, inasmuch as very similar alterations may be produced by various 
causes. When, however, in a supposed ease of pregnancy advanced 
beyond the period indicated, the cervix is found to be elongated, dense, 
and projecting into the vaginal canal, the non-existence of pregnancy 
may be safely inferred. Therefore the negative value of this sign i- 
of more importance than the positive. In connection with this may 
be mentioned a sign of pregnancy to which attention has recently 
been drawn by Hegar. 2 It consists in a peculiar elasticity of the 
lower segments of the uterus, made out by vaginal or rectal examina- 
tion. It may serve to differentiate the pregnant uterus from certain 
uterine enlargements due to tumor in cases in which the diagnosis is 
doubtful. 

Ballottement, when distinctly made out, is a very valuable indica- 
tion of pregnancy. It consists in the displacement, by the examining 
finger, of the foetus, which floats up in the liquor amnii, and falls back 
again on the tip of the finger with a slight tap which is exceedingly 
characteristic. 

In order to practise it most easily, the patient is placed on a couch 
or bed in a position midway between sitting and lying, by which the 
vertical diameter of the uterine cavity is brought into correspondence 
with that of the pelvis. Two fingers of the right hand are then passed 
high up into the vagina in front of the cervix. The uterus being now- 
steadied from without by the left hand, the intra-vaginal finger- press 
the uterine wall suddenly upward, when, if pregnancy exist, the foetus 
is displaced, and in a moment fall- back again, imparting a distinct 
impulse to the fingers. When easily appreciable it may be considered 
as a certain sign, for although an anteflexed fundus, or a calculus in 

t 1 In a case where ectopic pregnancy had been long Buspected in this city, the movements here 
noted decided the gestation to be uterine, and the woman delivered herself. She had a bitid uterus, 
-with one half empty, and admitting a sound four and a half inches.— Ed. ] 
utralblatt fiirGvnak., 1SVT, Bd. xi. B - 



158 PREGNANCY. 

the bladder, may give rise to somewhat similar sensations, the absence 
of other indications of pregnancy would really prevent error. Bal- 
lottement is practised between the fourth and seventh months. Before 
the former time the foetus is too small, while at a later period it is 
relatively too large, and can no longer be easily made to rise upward 
in the surrounding liquor amnii. The absence of ballottement must 
not be taken as proving the non-existence of pregnancy, for it may be 
inappreciable from a variety of causes, such as abnormal presentations, 
or the implantation of the placenta upon the cervix uteri. 

Vaginal Pulsation. — There are also some other vaginal signs of 
pregnancy of secondary consequence. Amongst these is the vaginal 
pulsation pointed out by Osiander resulting from the enlargement of 
the vaginal arteries, which may sometimes be felt beating at an early 
period. Often this pulsation is very distinct, at other times it cannot 
be felt at all. and it is altogether unreliable, as a similar pulsation may 
be felt in various uterine diseases. 

Uterine Fluctuation. — Dr. Rasch has drawn attention to a pre- 
viously undescribed sign which he believes to be of importance in the 
diagnosis of early pregnancy. 1 It consists in the detection of fluctua- 
tion, through the anterior uterine wall, depending on the presence of 
the liquor amnii. In order to make this out, two fingers of the right 
hand must be used, as in ballottement, while the uterus is steadied 
through the abdomen. Dr. Easch states that by this means the en- 
larged uterus in pregnancy can easily be distinguished from enlarge- 
ment depending on other causes, and that fluctuation can always be 
felt as early as the second month. If it is associated with suppressed 
menstruation and darkened areola?, he considers it a certain sign. In 
order to detect it, however, considerable experience in making vaginal 
examinations is essential, and it can hardly be depended on for gen- 
eral use. 

A peculiar deep violet hue of the vaginal mucous membrane was 
relied on by Jacquemin 2 and Kliige as affording a readily observed 
indication of pregnancy. In most cases it is well marked ; sometimes, 
indeed, the change of color is very intense, and it evidently depends 
on the congestion produced by pressure of the enlarged uterus. Chad- 
wick, of Boston, has recently reinvestigated this sign, and attributes 
to it a high diagnostic value. 3 It has been generally stated to be 
unreliable, as a similar discoloration is said to be produced by the 
pressure of large uterine fibroids. This, however, Chadwick declares 
is not the case. 

Auscultatory Signs of Pregnancy. — By far the most important 
signs are those which can be detected by abdominal auscultation, and 
one of these — the hearing of the fcetal heart-sounds — forms the 
onlv sign which per se, and in the absence of all others, is perfectly 
reliable. 

1 Brit. Med. Journ., 1S73. vol. ii. p. 261. 

- The credit of first drawing- attention to this sign of pregnancy is generally given to Jacquemier, 
a distinguished French obstetrician, who wrote a work on Midwifery, it is due. however, to 
Jacquemin, medecin en chef de la prison de Mazas, and is, in fact, attributed to him in Jacquemier's 
work (Manuel des Accouehements, par J. Jacquemier. Paris. 1846, vol. i. p. 215). 

3 Transactions of the American Gynecological Society, 1886, vol. ii. p. 399. 



SIGN'S AND BYMPTOMS OF PRB Y. 

The fact that the sounds of the foetal heart are audible during ad- 
vanced pregnancy was first pointed out by Mayor, of Geneva, in L818, 
and the main tacts in connection with foetal auscultation were subse- 
quently worked out by Kergaradec, Naegele, Evory Kennedy, and 
other observers. The pulsations firsl become audible, as a rule, in the 
course of the fifth month, or about the middle of the fourth month. 
In exceptional circumstances, and by practised observers, they have 
been heard earlier. Depaul believes that he detected them as early as 
the eleventh week, and Bouth has also detected them at an earlier 
period by vaginal stethoscopy, which, however, for obvious reasons, 
cannot he ordinarily employed. Naegele never heard them before the 
eighteenth week, more generally at the end of the twentieth, and for 
practical purposes the pregnancy must he advanced to the fifth month 
before we can reasonably expect to detect them. From this period up 
to term they ean almost always he heard to a certainty, if not at the 
first attempt, at least afterward, if we have the opportunity of making 
repeated examination-. Accidental circumstances, such as the presence 
of an unusual amount of flatus in the intestines, may deaden the 
sound- for a time, but not permanently. Depaul only failed to hear 
them in 8 eases out ot' 906 examined during the last three months of 
pregnancy; and out of 180 cases which Dr. Anderson, of Glasgow, 
carefully examined, he only failed in 12, and in each of these the child 
was stillborn. They, therefore, form not only a most certain indication 
of pregnancy, but of the life of the foetus also. 

The sound has always been likened to the double tic-tac of a watch 
heard through a pillow, which it closely resembles. It consists of two 
beats, separated by a short interval, the first being the loudest and 
most distinct, the second being sometimes inaudible. The rapidity of 
the foetal pulsations forms an important means of distinguishing them 
from transmitted maternal pulsations with which they might be con- 
founded. Their average number is stated by Slater, who made numer- 
ous observations on this point, to be 132, but sometimes they reach as 
high as 140. and sometimes as low as 120. It will thus be seen that 
the pulsations are always much more rapid than those of the mother's 
heart, unless, indeed, the latter be unduly accelerated by transient 
mental emotion or disease. To avoid mistake-, whenever the fetal 
heart is heard its rate of pulsation should be carefully counted, and 
compared with that of the mother's pulse : if the rate differ, we may 
be sure that no error has been made. The rapidity of the fetal pulsa- 
tions remains, as a rule, the same during the whole period of preg- 
nancy, while their intensity gradually increases. They may. however. 
be temporarily increased or diminished in frequency by disturbing 
causes, such as the pressure of the stethoscope, which, exciting 
tumultuous movement- of the fetus, may induce greatly incn 
frequency of its heart-beat-. So also they may be greatly modified 
during labor, after the escape of the liquor amnii, when the contrac- 
tions of the uterus have a very distinct influence on the foetus. Ail 
acceleration or irregularity of the pulsations, made out in the co - 
of a prolonged labor, may thus be of great practical importance, by 
indicating the necessity for prompt interference. Similar alterations. 



160 PREGNANCY. 

associated with tumultuous aud unusual foetal movements felt by the 
mother toward the end of pregnancy, may point to danger to the life 
of the fcetus during the latter months, and may even justify the induc- 
tion of premature labor. This is especially the case in women who 
have previously given birth to a succession of dead children owing 
to disease of the placenta, and, in them, careful and frequently 
repeated auscultations may warn us of the impending danger. 

The rapidity of the foetal heart has been supposed by some to* afford 
a means of determining the sex of the child before birth. Franken- 
hauser, who first directed attention to this point, is of opinion that the 
average rate of pulsations of the heart is considerably less in male than 
in female children, averaging 124 in the minute in the former, as 
against 144 in the latter. Steinbach makes the difference somewhat 
less, viz., 131 for males and 138 for females. He predicted the sex 
correctly by this means in 45 out of 57 cases, while Frankenhauser 
was correct in the whole 50 cases which he specially examined Avith 
reference to the point. Dr. Hutton, of New York, 1 was also correct 
in 7 cases which he fixed on for trial. Devilliers found the difference 
in the sexes to be the same as Steinbach ; he attributes it, however, 
to the size and weight rather than to the sex of the child, and believes 
the pulsations to be least numerous in large and well-developed chil- 
dren. As male children are usually larger than female, he thus 
explains the relatively less frequent pulsations of their hearts. Dr. 
dimming, of Edinburgh, also believes that the weight of the child has 
considerable influence on the frequency of its cardiac pulsations, so 
that a large female child may have a slower pulse than a small male. 2 
The point, however, is more curious than practical, and the rapidity 
of the pulsations certainly would not justify any positive prediction 
on the subject. Circumstances influencing the maternal circulation 
seem to have no influence on that of the foetus. 

The foetal heart-sounds are generally propagated best by the back 
of the child, and are. therefore, most easily audible when this is in 
contact with the anterior wall of the uterus, as is the case in the large 
majority of pregnancies. When the child is placed in the dorso- 
posterior position, the sounds have to traverse a larger amount of the 
liquor amnii, and are further modified by the interposition of the foetal 
limbs. They are, therefore, less easily heard in such cases, but even 
in them they can almost always be made out. As the foetus most 
frequently lies with the occiput over the brim of the pelvis, and the 
back of the child toward the left side of the mother, the heart-sounds 
are usually most distinctly audible at a point midway between the 
umbilicus and the left anterior superior spine of the ilium. In the 
next most common position, in which the back of the child lies to 
the right lumbar region of the mother, they are generally heard at a 
corresponding point at the right side, but in this case they are fre- 
quently more readily made out in the right flank, being then trans- 
mitted through the thorax of the child, which is in contact with the 
side of the uterus. In breech cases, on the other hand, the heart- 

i New York Med. Journ., 1872, vol. xvi. p. 68. 
2 Edin. Med. Joum., vol. 1875-76, pp. 230, 317, 418. 



SIGNS AND SYMPTOMS OF PREGNANCY. 161 

sounds are generally heard most distinctly above the umbilicus, and 
either to the right or left, according to the side toward which the bach 
of the child is placed. It m ill thus be s<vn that the place al which 
the foetal heart-sounds are heard varies with the position of the foetus; 
and this, when combined with the information derived from palpation, 
affords a ready means of ascertaining the presentation of the child 
before labor. The sounds are only audible over a limited space, 
about two or three inches in diameter; therefore, if we fail to detect 
them in one place, a careful exploration of the whole uterine tumor is 
necessary before Ave are satisfied that they cannot be heard. 

The only mistake that is likely to be made is taking the maternal 
pulsations, transmitted through the uterine tumor, for those of the 
foetal heart. A little care will easily prevent this error, and the fre- 
quency of the mother's pulse should always be ascertained before 
counting the supposed foetal pulsations. U these are found to be ] 20 
or more, while the mother's pulse is only 70 or 80, no mistake is 
possible. If the latter is abnormally quickened greater care may be 
necessary, but even then the rate of pulsation of each will be dis- 
similar. Braxton Hicks 1 has pointed out that in tedious labor, when 
the muscular powers of the mother are exhausted, the muscular su- 
surrus may produce a sound closely resembling the foetal pulsation ; 
but error from this source is obviously very improbable. 

In listening for the foetal heart-sounds the patient should be placed 
on her back, with the shoulders elevated and the knees flexed. The 
surface of the abdomen should be uncovered, and an ordinary stetho- 
scope employed, the end of which must be pressed firmly on the 
tumor, so as to depress the abdominal walls. The most absolute still- 
ness is necessary, as it is often far from easy to hear the sounds. 
Sometimes, after failing with the ordinary stethoscope, I have suc- 
ceeded with the binaural, which remarkably intensifies them. "When 
once heard they are most easily counted during a space of five seconds, 
as, on account of their frequency, it is not always possible to follow 
them over a longer period. 

When the foetal heart-sounds are heard distinctly, pregnancy may 
be absolutely and certainly diagnosed. The fact that we do not hear 
them does not, however, preclude the possibility of gestation, for the 
foetus may be dead, or the sounds temporarily inaudible. 

Other Sounds heard in Pregnancy. — There are some other sounds 
heard in auscultation which are of very secondary diagnostic value. 
One of these is the so-called umbilical or funic souffle, which was first 
pointed out by Evory Kennedy. It consists of a single blowing 
murmur, synchronous with the foetal heart-sounds, and most distinctly 
heard in the immediate vicinity of the point where these are most 
audible. Most authors believe it to be produced by pressure on the 
cord, either when it is placed between a hard part of the foetus and 
the uterine walls, or is twisted around the child's neck. Schroeder 
and Hecker detected it in fourteen or fifteen per cent, of all ease-, and 
the latter believed it to be caused by flexure of the first portion of the 



> Obst. Trans., 1874, vol. xv. p. 187. 
11 



162 PREGNANCY. 

cord near the umbilicus. For practical purposes it is quite valueless, 
and need only be mentioned as a phenomenon which an experienced 
anscultator may occasionally detect. 

The uterine souffle is a peculiar single whizzing murmur which is 
almost always audible on auscultation. It varies very remarkably in 
character and position. Sometimes it is a gentle blowing or even 
musical murmur ; at others it is load, harsh, and scraping ; sometimes 
continuous, sometimes intermittent. It may also be heard at any 
point of the uterus, but most frequently low down, and to one or other 
side ; more rarely above the umbilicus, or toward the fundus ; and it 
often changes its position so as to be heard at a subsequent ausculta- 
tion at a point where it was previously inaudible. It may be heard 
over a space of an inch or two only, or in some cases over the whole 
uterine tumor ; or again, it may sometimes be detected simultaneously 
over two entirely distinct portions of the uterus. It is generally to 
be heard earlier than the foetal heart-sounds, often as soon as the 
uterus rises above the brim of the pelvis, and it can almost always be 
detected after the commencement of the fourth month. The sound 
becomes curiously modified by the uterine contractions during labor, 
becoming louder and more intense before the pain comes on, disappear- 
ing during its acme, and again being heard as it goes off. Hicks 
attributes to a similar cause, viz., the uterine contractions during 
pregnancy, the frequent variations in the sound which are character- 
istic of it. 1 The uterine souffle is also audible after the death of the 
foetus, and it is believed by some to be modified and to become more 
continuously harsh when that event has taken place. 

Very various explanations have been given of the causes of this 
sound. For long it was supposed to be formed in the vessels of the 
placenta, and hence the name " placental souffle ," by which it is often 
talked of; or if not in the placenta, in the uterine vessels in its imme- 
diate neighborhood. The non-placental origin of the sound is suffi- 
ciently demonstrated by the fact that it may be heard for a considerable 
time after the expulsion of the placenta. Some have supposed that it 
is not formed in the uterus at all, but in the maternal vessels, especially 
the aorta and the iliac arteries, owing to the pressure to which they 
are subjected by the gravid uterus. The extreme irregularity of the 
sound, its occasional disappearance, and its variable site, seem to be 
conclusive against this view. The theory which refers the sound to 
the uterine vessels is that which has received most adherents, and 
which best meets the facts of the case ; but it is by no means easy, or 
even possible, to account for the exact mode of its production in them. 
Each of the explanations which have been given is open to some 
objection. It is far from unlikely that the intermittent contractions 
of the uterine fibres, which are known to occur during the whole 
course of pregnancy, may have much to do with it, by modifying, at 
intervals, the rapidity of the circulation in the vessels. Its production 
in this manner may also be favored by the chlorotic state of the blood, 
to Avhich £azeaux and Scanzoni are inclined to attribute an important 

i Op. cit.,p. 223. 



SIGNS AND SYMPTOMS OF PREGNANCY. 

influence, likening it to the amende murmur bo frequently beard in the 
vessels in weakly women. 

From a diagnostic point of view the uterine souffle is of very 
secondary importance, because a similar sound is very generally 
audible in large fibroid tumors of the uterus, and even in some few 
ovarian tumors; it is, therefore, of little or no value in assisting ns t<> 
decide the character of the abdominal enlargement. The supposed 
dependence of the sound on the placental circulation has caused its 
site to be often identified with that of the placenta. It is, however, 
most frequently heard at the lower part of the uterus, while the 
placenta is generally attached near the fundus, so that its position 
cannot be taken as any safe guide in determining the situation of that 
organ. 

Occasionally, in practising auscultation, irregular sounds of brief 
duration may be heard, which are not susceptible of accurate descrip- 
tion, and which doubtless depend on the sudden movement of tin? 
foetus in the liquor amnii, or on the impact of its limbs on the uterine 
walls. When heard distinctly they are characteristic of pregnancy ; 
and they may be sometimes heard when the other sounds cannot be 
detected. They are, however, so irregular, and so often entirely absent, 
that they ean hardly be looked upon in any other light than as occa- 
sional phenomena. 

Two other sounds have been described as being sometimes audible, 
which may be mentioned as matters of interest, but which are of no 
diagnostic value. One is a rustling sound, said by Stoltz to be audible 
in cases in which the foetus is dead, and which he refers to gaseous 
decomposition of the liquor amnii ; its existence is, however, extremely 
problematical. The other is a sound heard after the birth of the child, 
and referred by Caillant to the separation of the placental adhesions. 
He describes it as a series of rapid short scratching sounds, similar to 
those produced by drawing the nails across the seat of a horsehair 
sofa. Simpson 1 admitted the existence of the sound, but believed 
that it is produced by the mere physical crushing of the placenta, and 
artificially imitated it out of the body by forcing the placenta through 
an aperture the size of the os uteri. 

It will be seen, then, that although there are numerous signs and 
symptoms accompanying pregnancy, many of them are unreliable by 
themselves, and apt to mislead. Those which may be confidently 
depended on are the pulsations of the fetal heart, which, however, 
fail us in cases of dead children; the fetal movements when distinctly 
made out; ballottement ; the intermittent contractions of the uterus : 
and to these Ave may safely add the presence of milk in the breasts, 
provided we have to do with a first pregnancy. 

The remainder are of importance in leading ns to suspect pregnancy, 
and in corroborating and strengthening other symptoms, but they do 
not, of themselves, justify a positive diagnosis. 

i Selected Obstet. Works, p. 151. 



164 PBEGNANCY. 



CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY.— SPURIOUS 
PREGNANCY.— THE DURATION OF PREGNANCY.— SIGNS OF 
RECENT PREGNANCY. 

The differential diagnosis of pregnancy lias of late years assumed 
much importance on account of the advance of abdominal surgery. 
The cases are so numerous in which even the most experienced prac- 
titioners have fallen into error, and in which the abdomen has been 
laid open in ignorance of the fact that pregnancy existed, that the 
subject becomes one of the greatest consequence. Fortunately it is 
less so from an obstetrical than from a gynecological point of view, 
inasmuch as the converse error, of mistaking some other condition for 
pregnancy, is of far less consequence, as it is one which time will 
always rectify. But even in this way carelessness may lead to very 
serious injury to the character, if not to the health, of the patient ; 
and it will be well to refer briefly to some of the conditions most liable 
to be mistaken for pregnancy, and to the mode of distinguishing them. 

Adipose enlargement of the abdomen may obscure the diagnosis by 
preventing the detection of the uterus ; and if, as is not uncommon 
with women of great obesity, it is associated with irregular menstrua- 
tion, the increased size of the abdomen might be supposed to depend 
on pregnancy. The absence of corroborative signs, such as auscultatory 
phenomena, mammary changes, and the hardness of the cervix as felt 
•per vaginam, make it easy to avoid this error. 

Distention of the uterus by retained menstrual fluid, or watery 
secretion, is an occurrence of rarity that could seldom give rise to 
error. Still, it occasionally happens that the uterus becomes enlarged 
in this way, sometimes reaching even to the level of the umbilicus, 
and that the physical character of the tumor is not unlike that of the 
gravid uterus. The best safeguard against mistakes will be the pre- 
vious history of the case, which will always be different from that of 
ordinary pregnancy. Retention of the menses almost always occurs 
from some physical obstruction to the exit of the fluid, such as imper- 
forate hymen ; or if it occur in women who have already menstruated, 
we may usually trace a history of some cause, such as inflammation 
following an antecedent labor, which has produced occlusion of some 
part of the genital tract. The existence of a pelvic tumor in a girl 
who has never menstruated will of itself give rise to suspicion, as 
pregnancy under such circumstances is of extreme rarity. It will also 
be found that general symptoms have existed for a period of time 
considerably longer than the supposed duration of pregnancy as 
judged of by the size of the tumor. The most characteristic of them 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 165 

are periodic attacks of pain due to the addition, at cadi monthly 
period, to the quantity of retained menstrual fluid. Whenever, from 
any of these reasons, suspicion of the true character of the case baa 
arisen, a careful vaginal examination will generally clear it up. In 
most cases the obstruction will be in the vagina, and is at once de- 
tected, the vaginal canal above it, as felt per rectum, being greatly 
distended by fluid; and we may also find the bulging and imperforate 
hymen protruding through the vulva. The absence of mammary 
changes, and of ballottement, will materially aid ns in forming a 
diagnosis. 

The engorged and enlarged uterus frequently met with in women 
suffering from uterine disease, might readily be mistaken for an early 
pregnancy, if it happened to be associated with amenorrhoea. A little 
time would, of course, soon clear up the point, by showing that pro- 
gressive increase in size, as in pregnancy, does not take place. This 
mistake could only be made at an early stage of pregnancy, when a 
positive diagnosis is never possible. The accompanying symptoms 
— pain, inability to walk, and tenderness of the uterus on pressure — 
would prevent such an error. 

Ascites, per se, could hardly be mistaken for pregnancy ; for the 
uniform distention and evident fluctuation, the absence of any definite 
tumor, the site of resonance on percussion changing in accordance 
with alteration of the position of the woman, and the unchanged cer- 
vix and uterus, should be sufficient to clear up any doubt. Pregnancy 
may, hoAvever, exist with ascites, and this combination may be difficult 
to detect, and might readily be mistaken for ovarian disease associated 
with ascites. The existence of mammary changes, the presence of the 
softened cervix, ballottement, and auscultation — provided the sounds 
were not masked by the surrounding fluid — would afford the best 
means of diagnosing such a case. 

One of the most frequent sources of difficulty is the differential 
diagnosis of large abdominal tumors, either fibroid or ovarian, or of 
some enlargements due to malignant disease of the peritoneum or 
abdominal viscera. The most experienced have been occasionally 
deceived under such circumstances. As a rule, the presence of men- 
struation will prevent error, as this generally continues in ovarian 
disease, while in fibroids it is often excessive. The character of the 
tumor — the fluctuation in ovarian disease, the hard nodular masses iu 
fibroid — and the history of the case — especially the length of time 
the tumor has existed — will aid in diagnosis, while the absence of 
cervical softening (vide p. 143) and of auscultatory phenomena will 
further be of material value in forming a conclusion. Some of the 
most difficult cases to diagnose are those in which pregnancy compli- 
cates ovarian or fibroid disease. Then the tumor may more or less 
completelv obscure the physical signs of pregnancy. The usual shape 
of the abdomen will generally be altered considerably, and Ave may 
be able to distinguish the gravid uterus, separated from the ovarian 
tumor by a distinct sulcus, or with the fibroid masses cropping out 
from its surface. Our chief reliance must then be placed in the altera- 
tion of the cervix, and in the auscultatory signs of pregnancy. 



166 PKEGNANCY. 

Spurious Pregnancy. — The condition most likely to give rise to 
errors is that very interesting and peculiar state known as spurious 
pregnancy, or pseudocyesis. In this, most of the usual phenomena of 
pregnancy are so strangely simulated that accurate diagnosis is often 
far from easy. There are hardly any of the more apparent symptoms 
of pregnancy which may not be present in marked cases of this kind. 
The abdomen may become prominent, the areola? altered, menstrua- 
tion arrested, and apparent foetal motions felt ; and, unless suspicion is 
aroused, and a careful physical examination made, both the patient 
and the practitioner may easily be deceived. 

There is no period of the childbearing life in which spurious preg- 
nancy may not be met with, but it is most likely to occur in elderly 
women about the climacteric period, when it is generally associated 
with ovarian irritation connected with the change of life ; or in 
younger women, who are either very desirous of hnding themselves 
pregnant, or who, being unmarried, have subjected themselves to the 
chance of being so. In all cases the mental faculties have much to 
do with its production, and there is generally either very marked 
hysteria, or even a condition closely allied to insanity. Spurious 
pregnancy is by no means confined to the human race. It is well 
known to occur in many of the lower animals. Harvey related in- 
stances in bitches, either after unsuccessful intercourse, or in connec- 
tion with their being in heat, even when no intercourse had occurred. 
In such cases the abdomen swelled, and milk appeared in the mammas. 
Similar phenomena are also occasionally met with in the cow. In 
these instances, as in the human female, there is probably some 
morbid irritation of the ovarian system. 

The physical phenomena are often very well marked. The apparent 
enlargement is sometimes very great, and it seems to be produced by 
a projection forward of the abdominal contents due to depression of 
the diaphragm, together with rigidity of the abdominal muscles, and 
may even closely simulate the uterine tumor on palpation. After the 
climacteric it is frequently associated, as Gooch pointed out, with an 
undue deposit of fat in the abdominal walls and omentum, so that 
there may be even some dulness on percussion, instead of resonance of 
the intestines. The foetal movements are curiously and exactly simu- 
lated, either by involuntary contractions of the abdominal walls, or 
by the movement of flatus in the intestines. The patient also gener- 
ally fancies that she suffers from the usual sympathetic disorders of 
jDregnancy, and thus her account of her symptoms will still further 
tend to mislead. 

JSot only may the supposed pregnancy continue, but, at what would 
be the natural term of delivery, all the phenomena of labor may 
supervene. Many authentic cases are on record in which regular 
pains came on, and continued to increase in force and frequency until 
the actual condition was diagnosed. Such mistakes, however, are onlv 
likely to happen when the statements of the patient have been received 
without further inquiry. When once an accurate examination has 
been made, error is no longer possible. 

We shall generally find that some of the phenomena of pregnancy 



DIFFERENTIAL DIAGNOSIS OP PREGNANCY. L67 

are absent Possibly menstruation, more or less irregular, may have 
continued. Examination per vaginam will at once clear up the case, 
by showing that the uterus is not enlarged, and that the cervix is 
unaltered. It may then he very difficult to convince the patient or 
her friends that her symptoms have misled her, and for this purpose 
the inhalation of chloroform is of great value. As consciousness is 
abolished, the semi-voluntary projection of the abdominal muscles i- 
prevented, the large apparent tumor vanishes, and the bystanders can 
be readily convinced that none exists. As the patient recovers the 
tumor again appears. 

Duration of Pregnancy.— The duration of pregnancy in the human 
female has always formed a fruitful theme for discussion among ob- 
stetricians. The reasons which render the point difficult of decision 
are obvious. As the large majority of cases occur in married women. 
iu whom intercourse occurs frequently, there is no means of knowing 
the precise period at which conception took place. The only datum 
which exists for the calculation of the probable date of delivery is the 
cessation of menstruation. It is quite possible, however, and indeed 
probable, that conception occurred, in a considerable number of in- 
stances, not immediately after the last period, but immediately before 
the proper epoch for the occurrence of the next. Hence, as the inter- 
val between the end of one menstruation and the commencement of 
the next averages twenty-five days, an error to that extent is always 
possible. Another source of fallacy is the fact, which has generally 
been overlooked, that even a single coitus docs not fix the date of 
conception, but only that of insemination. It is well known that in 
many of the lower animals the fertilization of the ovule does not take 
place until several days after copulation, the spermatozoa remaining in 
the interval in a state of active vitality within the genital tract. It 
has been shown by Marion Sims that living spermatozoa exist in the 
cervical canal in the human female some days after intercourse. It is 
very probable, therefore, that in the human female, as in the lower 
animals, a considerable but unknown interval occurs between insem- 
ination and actual impregnation, which may render calculations as to 
the precise duration of pregnancy altogether unreliable. 

A large mass of statistical observations exist respecting the average 
duration of gestation, which have been drawn up and collated from 
numerous sources. It would serve no practical purpose to reprint the 
voluminous tables on this subject that are contained in obstetrical 
works. They are based on two principal methods of calculation. 
First, we have the length of time between the cessation of menstruation 
and delivery. This is found to vary very considerably, but the largest 
percentage of deliveries occurs between the 274th and 280th day after 
the cessation of menstruation, the average day being the 27Sth ; but. 
in individual instances, very considerable variations both above and 
below these limits are found to exist. Next we have a series of cases, 
from various sources, in which only one coitus was believed to have 
taken place. These are naturally always open to some doubt, but, on 
the whole, they may be taken as affording tolerably fair grounds for 
calculation. Here, as in the other mode of calculation, there are 



168 PREGNANCY. 

marked variations, the average length of time, as estimated from a 
considerable collection of cases, being 275 days after the single inter- 
course. It may, therefore, be taken as certain that there is no definite 
time which we can calculate on as being the proper duration of preg- 
nancv, and, consequently, no method of estimating the probable date 
of delivery on which we can absolutely rely. 

Methods of Predicting the Probable Date of Delivery. — The 
prediction of the time at which the confinement may be expected is, 
however, a point of considerable practical importance, and one on 
which the medical attendant is always consulted. Various methods 
of making the calculation have been recommended. It has been 
customary in this country, according to the recommendation of Mont- 
gomery, to fix upon ten lunar months, or 280 days, as the probable 
period of gestation, and, as conception is supposed to occur shortly 
after the cessation of menstruation, to add this number of days to any 
day within the first week after the last menstrual period as the most 
probable period of delivery. As, however, 278 days is found to be 
the average duration of gestation after the cessation of menstruation, 
and as the method makes the calculation vary from 281 to 287 days, it 
is evidently liable to fix too late a date. Xaegele's method was to count 
seven days from the first appearance of the last menstrual period, and 
then reckon backward three months as the probable date. Thus, if a 
patient last commenced to menstruate on August 10, counting in this 
way from August 17 would give May 17 as the probable date of the 
delivery. 

Matthews Duncan has paid more attention than anyone else to the 
prediction of the date of delivery.- His method of calculating is based 
on the fact of 278 days being the average time between the cessation 
of menstruation and parturition ; and he claims to have had a greater 
average of success in his predictions than on any other plan. His 
rule is as follows : " Find the day on which the female ceased to 
menstruate, or the first day of being what she calls ' well/ Take that 
day nine months forward as 275 — unless February is included, in 
which case it is taken as 273 — days. To this add three days in the 
former case, or five if February is in the count, to make up the 278. 
This 278th day should then be fixed on as the middle of the week, or, 
to make the prediction more accurate, of the fortnight in which the 
confinement is likely to occur, by which means allowance is made for 
the average variation of either excess or deficiency." 

Various periodoscopes and tables for facilitating the calculation 
have been made. The periodoscope of Dr. Tyler Smith is very useful 
for reference in the consulting-room, giving at a glance a variety of 
information, such as the probable period of quickening, the dates for the 
induction of premature labor, etc. The following table, prepared by Dr. 
Protheroe Smith, is also easily read, and is very serviceable : 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY 



L69 



Table for Calculating mr. Period op Otebo-gestation. 





Nino calendar month-. 




Ten lunar months. 




From 


To 


Days. 




Dayi. 


January 


1 


September SO 


October 7 


280 


lebruary 


1 


October 31 


273 


November 7 




March 


1 


November 30 


275 


December 5 




April 


1 


December 31 


275 


January 5 




May 


1 


January 31 


27C 


February I 




June 


1 


February 2s 


273 


March 7 




July 


1 


March 31 


•274 


April 6 




August 


1 


April 30 


27:i 


May 7 


•j.,, 


September 


1 


May 31 


27:; 


June 7 




October 


1 


June 30 


27:; 


July 7 




November 


1 


July 31 


27:; 


August 7 




December 


1 


August 31 


274 


September (*, 


280 



The date at which the quickening lias been perceived is relied on 
by many practitioners, and still more by patients, in calculating the 

probable date of delivery, as it is generally supposed to occur at the 
middle of pregnancy. The great variations, however, of the time at 
which this phenomenon is first perceived, and the difficulty which is 
so often experienced of ascertaining its presence with any certainty, 
render it a very fallacious guide. The only times at which the per- 
ception of quickening is likely to prove of any real value are when 
impregnation has occurred during lactation (when menstruation is 
normally absent), or when menstruation is so uncertain and irregular 
that the date of its last appearance cannot be ascertained. As quick- 
ening is most commonly felt during the fourth month, more frequently 
in its first than in its last fortnight, it may thus afford the only guide 
we can obtain, and that an uncertain one, for predicting the date of 
delivery. 

Is Protraction of Gestation Possible ? — From a medico-legal 
point of view the question of the possible protraction of pregnancy 
beyond the average time, and of the limits within which such pro- 
traction can be admitted, is of very great importance. The law on 
this point varies considerably in different countries. Thus, in France 
it is laid down that legitimacy cannot be contested until 300 days 
have elapsed from the death of the husband, or the latest possible 
opportunitv for sexual intercourse. This limit is also adopted by 
Austria, while in Prussia it is fixed at 302 days. In England and 
America no fixed date is admitted, but while 280 days is admitted as 
the "legitinium tempus pariendi," each case in which legitimacy i- 
questioned is to be decided on its own merits. At the early part of 
the century the question was much discussed by the leading obstetricians 
in connection with the celebrated Gardner peerage case, and a con- 
siderable difference of opinion existed among them. Since that time 
manv apparentlv perfectly reliable cases have been recorded, in which 



1 The above obstetric "Ready Reckoner" consists of two columns, one of calendar, the other of 
lunar, months, and mav be read as follows : A patient has ceased to menstruate on July 1 : her 
confinement mav be expected at soonest about March 31 {.the end of nine calendar months)) or at 
latest on April Qdhe end of ten lunar months). Another has ceased to menstruate on January 20 ; 
her confinement mav be expected on September 30, plus twenty days (the md of nine calendar 
months), at soonest ; or on October 7, plus twenty days {the end of ten lunar months), at latest. 



170 PREGNANCY. 

the duration of gestation was obviously much beyond the average, and 
in which all sources of fallacy were carefully excluded. 

Not to burden these pages with a number of cases, it may suffice to 
refer, as examples of protraction, to four well-known instances recorded 
by Simpson, 1 in which the pregnancy extended respectively to 336, 
332, 319, and 324 days after the cessation of the last menstrual period. 
In these, as in all cases of protracted gestation, there is the possible 
source of error that impregnation may have occurred just before the 
expected advent of the next period. Making an allowance of 23 days 
in each instance for this, we even then have a number of days much 
above the average, viz., 313, 309, 296, and 301. Numerous instances 
as curious may be found scattered through obstetric literature. Indeed, 
the experience of most acccoucheurs will parallel such cases, which 
may be more common than is generally supposed, inasmuch as they 
are only likely to attract attention when the husband has been sepa- 
rated from the wife beyond the average and expected duration of the 
pregnancy. 

The evidence in favor of the possible prolongation of gestation is 
greatly strengthened by what is known to occur in the lower animals. 
In some of these, as in the cow and the mare, the precise period of 
insemination is known to a certainty, as only a single coitus is per- 
mitted. Many tables of this kind have been constructed, and it has 
been shoAvn that there is in them a very considerable variation. In 
some cases in the cow it has been found that delivery took place 45 
days, and in the mare 43 days, after the calculated date. Analogy 
would go strongly to show that what is known to a certainty to occur 
in the lower animals may also take place in the human female. The 
fact, indeed, is now very generally admitted ; but we are still unable 
to fix, with any degree of precision, on the extreme limit to which 
protraction is possible. Some practitioners have given cases in which, 
on data which they believe to be satisfactory, pregnancy has been 
extremely protracted ; thus Meigs and Adler record instances which 
they believed to have been prolonged to over a year in one case, and 
over fourteen months in the other. These are, however, so problem- 
atical that little weight can be attached to them. On the whole, it 
would hardly be safe to conclude that pregnancy can go more than 
three or four weeks beyond the average time. This conclusion is jus- 
tified by the cases we possess in which pregnancy followed a single 
coitus, the longest of which was 295 days. 

Dr. Duncan ' l is inclined to refuse credence to every case of supposed 
protraction unless the size and weight of the child are above the 
average, believing that lengthened gestation must of necessity cause 
increased growth of the child. This point requires further investiga- 
tion, and it cannot be taken as proved that the fetus necessarily must 
be large because it has been retained longer than usual in utero ; or, 
even if this be admitted, it may have been originally small, and so, at 
the end of the protracted gestation, be little above the average weight. 
There are, however, many cases which certainly prove that a prolonged 

1 Obstet. Memoirs, p. 84. 

2 Fecundity and Fertility, p. 348. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 171 

pregnancy is at least often associated with an unusually developed 
foetus. Dr. Duncan himself cites several, and a very interesting one 
is mentioned by Leishman, in which delivery took place 2ii"> days after 
a single coitus, the child weighing 1:2 lbs. 3 oz. 

It seems possible that, in some eases of protracted pregnancy, labor 
actually came on at the average time, but, on account of faulty posi- 
tions of the uterus or other obstructing cause, the pains were ineffective 
and ultimately died away, not recurring for a considerable time. 
Joulin relates some instances of* this kind. In one of them the labor 
was expected from the 20th to the 25th of October. Me was sum- 
moned on the 23d, and found the pains regular and active, but inef- 
fective ; after lasting the whole of the 24th and 25th they died away, 
and delivery did not take place until November 25th, after the lapse 
of a month. In this instance the apparent cause of difficulty was 
extreme anterior obliquity of the uterus. A precisely similar case 
came under my own observation. The lady ceased to menstruate on 
March 16, 1870. On December 12th, that is, on the 273d day, strong 
labor pains came on, the os dilated to the size of a florin, and the 
membranes became tense and prominent with each pain. After last- 
ing all night they gradually died away, and did not recur until 
January 12th, 304 days from the cessation of the last period. Here 
there was no assignable cause of obstruction, and the labor, when it 
did come on, Avas natural and easy. 

The curious fact that in both these cases, as in others of the same 
kind that are recorded, labor came on exactly a month after the 
previous ineffectual attempt at its establishment, affords, so far as it 
goes, an argument in favor of the view maintained by many that labor 
is apt to come on at what would have been a menstrual period. 

Signs of Recent Delivery. — From a forensic point of view it 
often becomes of importance to be able to give a reliable opinion as 
to the fact of delivery having occurred, and a few words may be here 
said as to the signs of recent delivery. Our opinion is only likely to 
be sought in cases in which the fact of delivery is denied, and in which 
we must, therefore, entirely rely on the results of a physical examina- 
tion. If this be undertaken within the first fortnight after labor, a 
• positive conclusion can be readily arrived at. 

At this time the abdominal walls will still be found loose and flaccid, 
and bearing very evident marks of extreme distention in the cracks 
and fissures of the cutis vera. These remain permanent for the rest 
of the patient's life, -and may be safely assumed to be signs of an 
antecedent pregnancy, provided we can be certain that no other cause 
of extreme abdominal distention has existed, such as ascites or ovarian 
tumor. 

Within the first few days after delivery, the hard round ball formed 
by the contracted and empty uterus can easily be felt by abdominal 
palpation, and more certainly by combined external and internal ex- 
amination. The process of involution, however, by which the uterus 
is reduced to its normal size, is so rapid that after the first week it 
can no longer be made out above the brim of the pelvis. In cases in 
which an accurate diagnosis is of importance, the increased length of 



172 PREGNANCY. 

the uterus can be ascertained by the uterine sound, and its cavity will 
measure more than the normal two and a half inches for at least a 
month after delivery. It should not be forgotten that the uterine 
parietes are now undergoing fatty degeneration, and that they are 
more than usually soft and friable, so that the sound should be used 
with great caution, and only when a positive opinion is essential. The 
state of the cervix and of the vagina may afford useful information. 
Immediately after delivery the cervix hangs loose and patulous in the 
vagina, but it rapidly contracts, and the internal os is generally 
entirely closed after the eighth or tenth day. The remainder of the 
cervix is longer in returning to its normal shape and consistency. It 
is generally permanently altered after delivery, the external os remain- 
ing fissured and transverse, instead of circular with smooth margins, 
as in virgins. The vagina is at first lax, SAVollen, and dilated, but 
these signs rapidly disappear, and cannot be satisfactorily made out 
after the first few days. The absence of the fourchette may be recog- 
nized, and is a persistent sign. 

The presence of the lochia affords a valuable sign of recent delivery. 
For the first few days they are sanguineous, and contain numerous 
blood corpuscles, epithelial scales, and the debris of the decidua. 
After the fifth day they generally change in color, and become pale 
and greenish, and from the eighth or ninth day till about a month 
after delivery they have the appearance of thick opalescent mucus. 
They have, however, a peculiar, heavy, sickening odor, which should 
prevent their being mistaken for either menstruation or leucorrhoeal 
discharge. 

The appearance of the breasts will also aid the decision, for it is 
impossible for the patient to conceal the turgid, swollen condition of 
the mammae, with the darkened areolae, and, above all, the presence 
of milk. If, on microscopic examination, the milk is found to contain 
colostrum corpuscles, the fact of very recent delivery is certain. In 
women who do not nurse it should be remembered that the secretion 
of milk often rapidly disappears, so that its absence cannot be taken 
as a sign that delivery has not taken place. On the whole, there 
should be no difficulty in deciding that a woman has been delivered, 
as some of the signs are persistent for the rest of her life ; but it is not - 
so easy, unless we see the case within the first eight or ten days, to 
say how long it is since labor took place. 



ABNORMAL PREGNANCY. 



173 



CHAPTEE VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, 
SUPERFCETATION, EXTRA-UTERINE FCETATION, AND MISSED 
LABOR. 



The occurrence of more than one foetus in uiero is far from un- 
common, but there are circumstances connected with it which justify 
the conclusion that plural births must not be classified as natural forms 
of pregnancy. The reasons for this statement have been well collected 
by Dr. Arthur Mitchell, 1 who conclusively shows that not onlv is 
there a direct increase of risk to the mother and her offspring, but 
that many abnormalities, such as idiocy, imbecility, and bodily de- 
formity, occur with much greater frequency in twins than in single- 
born children. He concludes that "the whole history of twin births 
is exceptional, indicates imperfect development and feeble organization 
in the product, and leads us to regard twinning in the human species 
as a departure from the physiological rule, and therefore injurious to 
all concerned/' 

The frequency of multiple births varies considerably under dif- 
ferent circumstances. Taking the average of a large number of cases 
collected by authors in various countries, we find that twin pregnancies 
occur about once in 87 labors ; triplets once in 7679. A certain num- 
ber of quadruple pregnancies, and some cases of early abortion in 
which there were five foetuses, are recorded, so that there can be no 
doubt of the possibility of such occurrences ; but they are so extremely 
uncommon that they may be looked upon as rare exceptions, the 
relative frequency of which can hardly be determined. 

The frequency of multiple pregnancy varies remarkably in different 
races and countries. The following table 2 will show this at a glance : 

Relative Frequency of Multiple Pregnancies in Europe. 



Countries. 


Proportion of 

twin to single 

births. 


Proportion of 
triplets. 


Proportion of 
quadruplets. 


England 


1 : 110 


1 : 0,720 




Austria ....... 


1 : 94 






Grand Duchy of Baden .... 


1 : 89 


1 : 0,575 




Scotland 


1 : 95 






France 


1 : 99 


1 : 8,256 


1 : 2,074,306 


Ireland 


1 : 04 


1 : 4,995 


1 .- 167,226 


Mecklenburg-Schweriu .... 


1 : 08.9 


1 : 0,430 


1 : 183,236 


Norway 


1 : SI. 62 


1 : 5.442 




Prussia 


1 : 89 


1 : 7,820 


1 : 394,090 


Russia 


1 : 50.05 


1 : 4,054 




Saxony 


1 : 79 


1 : 1,000 


1 : 400,000 


Switzerland 


1 : 102 






Wurtembcrg 


1 : 862 


1 : 6,464 


1 : 110,991 



1 Med. Times and Gaz. , Nov. 1862. 

2 Puech : Des Naissances Multiples. 



174 PREGNANCY. 

It will be seen that the largest proportion of multiple births occurs in 
Russia, and that the number of triple births is greatest where twin 
pregnancies are most frequent. Puech concludes that the number of 
multiple pregnancies is in direct proportion to the general fecundity 
of the inhabitants. 

Dr. Duncan has deduced some interesting laws, with regard to the 
production of twins, from a large number of statistical observations j 1 
especially that the tendency to the production of twins increases as the 
age of the woman advances, and is greater in each succeeding pregnancy, 
exception being made for the first pregnancy, in which it is greater than 
in any other. Newly married women appear more likely to have twins 
the older they are. There can be no doubt that there is often a strong 
hereditary tendency in individual families to multiple births. A 
remarkable instance of this kind is recorded by Mr. Curgenven, 2 in 
which a woman had four twin pregnancies, her mother and aunt each 
one, and her grandmother two. Simpson mentions a case of quadruplets, 
consisting of three males and one female, who all survived, the female 
subsequently giving birth to triplets. 3 

Sex of Children. — In the largest number of cases of twins the 
children are of opposite sexes, next most frequently there are two 
females, and twin males are the most uncommon. Thus, out of 
59,178 labors, Simpson calculates that twin male and female occurred 
once in 199 labors, twin females once in 226, and twin males once in 
258. The proportion of male to female births, is also notably less in 
twin than in single pregnancies. 

Size of Foetuses. — Twins, and a fortiori triplets, are almost always 
smaller and less perfectly developed than single children. Hence the 
chances of their survival are much less, and Clarke calculates the 
mortality amongst twin children as one out of thirteen. Of triplets, 
indeed, it is comparatively rare that all survive ; while in quadruplets, 
premature labor and the death of foetuses are almost certain. It is a 
common observation that twins are often unequally developed at birth. 
By some this difference is attributed to one of them being of a different 
age to the other. It is probable, however, that in most of these cases, 
the full development of one foetus has been interfered with by pressure 
of the other. This is far from uncommonly carried to the extent of 
destroying one of the twins, which is expelled at term, mummified 
and flattened between the living child and the uterine wall. In other 
cases, when one foetus dies it may be expelled without terminating the 
pregnancy, the other being retained in utero and born at term ; and 
those who disbelieve in the possibility of superfoetation explain in this 
way the cases in which it is believed to have occurred. 

Multiple pregnancies depend on various causes. The most common 
is probably the simultaneous, or nearly simultaneous, maturation and 
rupture of two Graafian follicles, the ovules becoming impregnated at 
or about the same time. It by no means necessarily follows, even if 
more than one follicle should rupture at once, that both ovules should 

1 On Fecundity, Fertility, and Sterility, p. 99. 
a Obst. Trans., 1870. vol. xi. p. 106. 
s Obst. Works, p. 830. 



A BH R Id A L P R EG N A NOT . 175 

be impregnated. Thia is proved by the occurrence of cases in which 
there are two corpora lutea with only one foetus. There are numerous 
facts to prove that ovules thrown off within a short time of each Other 

may become separately impregnated, as in cases in which negro women 
have given birth to twins, one of which was pure negro, the other 
half-caste. 

It may happen, however, tnat a single Graafian follicle contains 
more than one ovule, as has actually been observed before its rapture; 
or, as is not uncommon in the egg of the fowl, an ovule may contain a 
double germ, each of which may give rise to a separate fetus. 

Arrangement of the Fcetal Membranes and Placentae. — The 
various modes in which twins may originate explain satisfactorily the 
variations which are met with in the arrangement of the foetal mem- 
branes, and in the form and eonnections of the placentae. In a large 
proportion of eases there are two distinct bags of membranes, the 
septum between them being composed of four layers, viz., the chorion 
and amnion of each ovum. The placentae are also entirely separate. 
Here it is obvious that each twin is developed from a distinct ovum, 
having its own chorion and amnion. On arriving in the uterus it is 
probable that each ovum becomes fixed independently in the mucous 
membrane, and is surrounded by its own decidua reflexa. As growth 
advances the decidna reflexa generally atrophies from pressure, as it is 
not usual to find more than four layers of membrane in the septum 
separating the ova. In other cases there is only one chorion, within 
which are two distinct amnions, the septum then consisting of two 
layers only. Then the placentas are generally in close apposition, and 
become fused into a single mass ; the cords, separately attached to each 
foetus, not infrequently uniting shortly before reaching the placental 
mass, their vessels anastomosing freely. In other more rare instances 
both foetuses are contained in a common amniotic sac ; but as the 
amnion is a purely foetal membrane, it is probable that, when this 
arrangement is met with, the originally existing septum between the 
amniotic sacs has been destroyed. In both these latter cases the twins 
mast have been developed from a single ovule containing a double 
germ, and Schroeder states that they are then always of the same sex, 
and have a striking similarity to each other. Dr. Brunton 1 has 
started a precisely opposite theory, and has tried to prove that twins 
of the same sex are contained in separate bags of membrane, while 
twins of opposite sexes have a common sac. He says that, out of 
twenty-five cases coming under his observation, in fifteen the children 
contained in different sacs were of the same sex, but in the remaining 
ten, in which there was only one sac, they were of opposite sexes. It 
is difficult to believe that there is not an error in these observations, 
since twins contained in a single amniotic sac do not occur nearly as 
often as ten times out of twenty-five cases, and no distinction is made 
between a common chorion with two amnions and a single chorion 
and amnion. The facts of double monstrosity also disprove this 
view, since conjoined twins must of necessity arise from a single 

i Obst. Trans., lsyo, vol. xl. p. 67. 



176 PREGNANCY. 

ovule with a double germ, aud there is no instance on record in which 
they were of opposite sexes. 

In triplets the membranes and placentae may be all separate, or, as 
is commonly the case, there is one complete bag of membranes, and a 
second having a common chorion, with a double amnion. It is prob- 
able, therefore, that triplets are generally developed from two ovules, 
one of which contains a double germ. 

Diagnosis of Multiple Pregnancy. — It is comparatively seldom 
that twin pregnancy can be diagnosed before the birth of the first 
child, and, even when suspicion has arisen, its indications are very 
defective. There is generally an unusual size and an irregularity of 
shape of the uterus, sometimes even a distinct depression or sulcus 
between the two foetuses. When such a sulcus exists it may be possi- 
ble to make out parts of each foetus by palpation on either side of the 
uterus. The only sign, however, on which the least reliance can be 
placed is the detection of two foetal hearts. If two distinct pulsations 
are heard at different parts of the uterus ; if, on carrying the stetho- 
scope from one point to another, there is an interspace where pulsa- 
tions are no longer audible, or when they become feeble, and again 
increase in clearness as the second point is reached ; and, above all, if 
we are able to make out a difference in frequency between them, the 
diagnosis is tolerably safe. It must be remembered, however, that 
the sounds of a single heart may be heard over a larger space than 
usual, and hence a possible source of error. Twin pregnancy, moreover, 
may readily exist without the most careful auscultation enabling us to 
detect a double pulsation, especially if one child lie in the dorso- 
]30sterior position, when the body of the other may prevent the trans- 
mission of its heart's beat. The so-called placental souffle is generally 
too diffuse and irregular to be of any use in diagnosis, even when it is 
distinctly heard at separate parts of the uterus. 

Superfcetation and Superfecundation. — Closely connected with 
the subject of multiple pregnancies are the conditions known as super- 
fecundation and superfoetation, regarding which there have been much 
controversy and difference of opinion. 

By the former is meant the fecundation, at or near the same period 
of time, of two separate ovules before the decidua lining the uterus 
has been formed, which by many is supposed to form an insuperable 
obstacle to subsequent impregnation. The possibility of this occur- 
rence has been incontestably proved by the class of cases already 
referred to, in which the same woman lias given birth to twins bearing 
evident traces of being the offspring of fathers of different races. 

By superfoetation is meant the impregnation of a second ovule when 
the uterus already contains an ovum which has arrived at a consider- 
able degree of development. The cases which are supposed to prove 
the possibility of this occurrence are very numerous. They are those 
in which a woman is delivered simultaneously of foetuses of very dif- 
ferent ages, one bearing all the marks of having arrived at term, the 
other of prematurity ; or those in which a woman is delivered of an 
apparently mature child, and, after the lapse of a few months, of 
another equally mature. The possibility of superfoetation is strongly 



ABNORMAL PREGNANCY. 177 

denied by many practitioners of eminence, and explanations are given 
which doubtless sccni to account satisfactorily lor a large proportion 
of the supposed examples. In the former class of cases it Is supposed, 
with much probability, that there is an ordinary twin pregnancy, i\\c 
development of one foetus being retarded by the presence inuteroof 
another. That this is not an uncommon occurrence is certain, and 
the fact has been already alluded to in treating of twin pregnancy. 
In cases of the latter kind it is possible that some of them may be 
due to separate impregnation in a bilobed uterus, the contents of one 
division being thrown oil' a considerable time before those of the other. 
Numerous authentic examples of this occurrence are recorded, but by 
tar the most remarkable is that related by Dr. Ross, of Brighton, 
which has been already referred to (p. 68). In this case the patient 
had previously given birth to many children without any suspicion of 
her abnornal formation having arisen, and, had it not been detected 
by Dr. Ross, the case might fairly enough have been claimed as an 
indubitable example of superfoetation. 

Making every allowance for these explanations, there remains a 
considerable number of cases which it is very difficult to account for, 
except on the supposition that the second child has been conceived a 
considerable time after the first. Those interested in the subject will 
find a large number of examples collected in a valuable paper by Dr. 
Bounar, of Cupar. 1 He has adopted the ingenious plan of consulting 
the records of the British peerage, where the exact date of the birth of 
successive children of peers is given, without, of course, any reasonable 
possibility of error, and he has collected numerous examples of births 
rapidly succeeding each other which are apparently inexplicable on 
any other theory. In one case he cites, a child was born September 
12, 1849, and the mother gave birth to another on January 24, 1850, 
after an interval of only 127 days. Subtracting from that 14 days, 
which Dr. Bonnar assumes to be the earliest possible period at which 
a fresh impregnation can occur after delivery, we reduce the gestation 
to 113 days — that is, to less than four calendar months. As both 
these children survived, the second child could not possibly have been 
the result of a fresh impregnation after the birth of the first ; nor could 
the first child have been a twin prematurely delivered ; for, if so, it 
must have only reached rather more than the fifth month, at which 
time its survival would have been impossible. 

Besides the numerous examples of cases of this kind recorded in 
most obstetric works, there are one or two of miscarriage in the early 
months, in which, in addition to a foetus of four or five months' growth, 
a perfectly fresh ovum of not more than a month's development was 
thrown off. One such case was shown at the Obstetrical Society in 
1862, which was reported on by Drs. Harley and Tanner, who stated 
that in their opinion it was an example of superfoetation. A still more 
conclusive case is recorded by Tyler Smith. 2 "A young married woman, 
pregnant for the first time, miscarried at the end of the fifth month, 
and some hours afterward a small clot was discharged, enclosing a 

i Edin. Med. Journ., 1864-65. 2 Manual of Obstetrics, p. 112. 

1^ 



178 



PREGNANCY 



perfectly healthy ovum of about one month. There were no signs of 
a double uterus in this case. The patient had menstruated regularly 
during the time she had been pregnant." This case is of special inter- 
est from the fact of the patient having menstruated during pregnancy 
— a circumstance only explicable on the same anatomical grounds 
which render superfoetation possible. So far as I know, it is the only 
instance in which the coincidence of superfoetation and menstruation 
during early pregnancy has been observed. 

The objections to the possibility of superfoetation are based on the 
assumptions that the decidua so completely fills up the uterine cavity 
that the passage of the spermatozoa is impossible ; that their passage 
is prevented by the mucous plug which blocks up the cervix ; and 



Fig. 81. 




Illustrating the cavity between the decidua vera and the decidua reflexa during the early 
months of pregnancy. (After Coste.) 



that when impregnation has taken place ovulation is suspended. It 
is, however, certain that none of these is an insuperable obstacle to a 
second impregnation. The first was originally based on the older and 
erroneous view which considered the decidua to be an exudation lining 
the entire uterine cavity, and sealing up the mouths of the Fallopian 
tubes and the aperture of the internal os uteri. The decidua reflexa, 
however, does not come into apposition with the decidua vera until 
about the eighth week of pregnancy, and, therefore, until that time 
there is a free space between the two membranes through which the 
spermatozoa might pass to the open mouth of the Fallopian tube, and 
in which a newly impregnated ovule might graft itself. A reference 
to the accompanying figure of a pregnancy in the third month, copied 
from Coste's work, will readily show that, as far as the decidua is con- 



ABNORMAL PREGNANCY. 170 

cerned, there is no mechanical obstacle to the descent an<l lodgmeni of 
another impregnated ovule (Fig. 81). Then, as regards the plug of 
mucus, it is pretty certain that this is in no way different from the 
mucus filling the cervix in the non-pregnanl state, which offers n<> 
obstacle at all to the passage of the spermatozoa. Lastly, respecting 
the cessation of ovulation during pregnancy, this, no doubt, is the 
rule, and probably satisfactorily explains the rarity of super foetati on. 
There are, however, a sufficient number of authenticated cases of men- 
struation during pregnancy, to prove that ovulation is not always 
absolutely in abeyance; and, as long as it occurs, there is unquestion- 
ably no positive mechanical obstruction, at least in the early months 
of pregnancy, in the way of the impregnation and lodgment of the 
ovules that are thrown off. The reasonable conclusion, therefore, 
seems to be that, although a large majority of the supposed cases are 
explicable in other ways, it cannot be admitted that sn perforation is 
either physiologically or mechanically impossible. 

Extra-uterine Pregnancy. — The most important of the abnormal 
varieties of pregnancy, if we consider the serious and very generally 
fatal results attending it, is the so-called extra-uterine gestation, or 
ectopic pregnancy, as some prefer to call it, which consists in the arrest 
and development of the ovum outside the cavity of the uterus. Of 
late years this subject has received much well-merited attention, which, 
it is to be hoped, may lead to the establishment of definite rules for 
the management of this most anxious and dangerous class of cases. 

Extra-uterine gestation has hitherto been generally divided into 
three chief classes, tubal, abdominal, and ovarian, according to the 
position in which the fecundated ovum is developed. It is to be noted 
that Lawson Tait, 1 who has an unrivalled experience in this subject, 
considers all extra-uterine pregnancies to be primarily tubal, the other 
varieties being developments after rupture, as will be subsequently 
explained. This view is strongly upheld by Bland Sutton, 2 who main- 
tains that "all forms of extra-uterine gestation pass their primary 
stage in the Fallopian tube." This opinion, although it is receiving 
an increasing number of supporters, cannot as yet be admitted as con- 
clusively proved, and, therefore, it seems best to retain, provisionally 
at least, the ordinary classification. 

Classification. — The following classes are generally admitted: 1st, 
and most common of all, tubal gestation, and as varieties of this, 
although by some made into distinct classes, (a) interstitial, (b) tubo- 
ovarian gestation, and (c) sub-peritoneo-pelvic, or intra-ligamevtous. In 
the first of these subdivisions the ovum is arrested in the part of the 
Fallopian tube that is situated in the substance of the uterine parietes; 
in the second, at or near the fimbriated extremity of the tube — so that 
part of its cyst is formed by the tube and part by the ovary ; in the 
third, an originally tubal pregnancy develops into the broad ligament, 
and continues this development beneath the peritoneum of the pelvic 
floor. 2d. Abdominal gestation, in which an impregnated ovum, 
instead of finding its way into the tube, falls into the peritoneal cavity, 

1 Lectures on Ectopic Pregnancv, 1888. 

2 Surgical Diseases of the Ovaries and Fallopian Tubes, 1891. 



180 PREGNANCY. 

and there becomes attached and developed ; this is the so-called " pri- 
mary" abdominal pregnancy, the possibility of which is denied by 
many recent writers ; or the so-called "secondary'' abdominal gesta- 
tion, in which an extra-uterine pregnancy, originally tubal, becomes 
ventral, through rupture of its cysts and escape of its contents into the 
abdominal cavity ; or in which an intra-ligamentous pregnancy con- 
tinues to develop until it lifts up the abdominal peritoneum, and forms 
a purely extra-peritoneal variety of abdominal gestation. This has 
been called by Hart and Carter sub-peritoneo-abdominal. 1 3d. Ova- 
rian gestation, the existence of which is denied by many writers of 
eminence, such as Velpeau and Arthur Farre, while it is maintained 
by others of equal celebrity, such as Kiwisch, Coste, and Hecker. It 
must be admitted that it is extremely difficult to understand how an 
ovarian pregnancy, in the strict sense of the word, can occur, for it 
implies that the ovule has become impregnated before the laceration of 
the Graafian follicle, through the coats of which the spermatozoa must 
have passed. Coste, indeed, believes that this frequently happens; 
but, while spermatozoa have been detected on the surface of the ovary, 
their penetration into the Graafian follicle has never been demonstrated. 
Farre has also clearly shown that in many cases of supposed ovarian 
pregnancy the surrounding structures were so altered that it was im- 
possible to trace their exact origin and to say to a certainty that the 
feet us was really within the substauce of the ovary. Kiwisch gives a 
reasonable explanation of these cases by supposing that sometimes the 
Graafian follicle may rupture, but that the ovule may remain within 
it without being discharged. Through the rent in the walls of the 
follicle the spermatozoa may reach and impregnate the ovule, which 
may develop in the situation in which it has been detained. The sub- 
ject has been ably considered by Puech, 2 who admits two varieties of 
ovarian pregnancy, according as the foetus has developed in a vesicle 
which has remained open, or in one which has closed immediately after 
fecundation. He considers that most cases of so-called ovarian preg- 
nancy are either dermoid cysts, ovario-tubal pregnancies, or abominal 
pregnancies in which the placenta is attached to the ovary, and that 
even in the rare cases of true ovarian pregnancies the progress and 
results do not differ from those of abdominal pregnancy. TThile, 
therefore, it is impossible to deny the existence of ovarian pregnancy, 
it must be considered to be a very rare and exceptional variety, the 
existence of which has never been actually proved, which, as far as 
treatment and results are concerned, does not differ from tubular or 
abdominal gestation. 4th. There are two rare varieties in which an 
ovum is developed either in the supplementary horn of a bi-lobed 
uterus, or in a hernial sac. 

For the sake of clearness, Ave may place these varieties of extra- 
uterine gestation in the following tabular form : 

1. Tubal— 

(a) Interstitial. (6) Tubo-ovarian, (c) Sub-peritoneo-pelvic. 

i "Sectional Anatomy of Advanced Extra-uterine Gestation," Edin. Med. Journ., October, 1887. 
2 Annal. de Gynec, 1S78, torn. x. p. 102. 



ABNORMAL PREGNANCY. 181 

2. Abdominal — 

(a) Primary (?), (6) Secondary, 
.'i. 0varian(7). 
1. In birlobed uterus, hernial, etc. 

Causes. — 'Flic etiology of extra-uterine fcetation in any individual 
case must necessarily be almost always obscure. Broadly speaking, it 
may be said that extra-uterine foetation may be produced by any con- 
dition which prevents or fenders difficult the passage of the ovule to 
the uterus while it does not prevent the access of the spermatozoa to 
the ovule. Tims inflammatory thickening of the coats of the Fallopian 
tubes, by lessening their calibre, but not sufficiently so as to prevent 
the passage of the spermatozoa, may interfere with the movements 
of the tube which propel the ovum forward, and so cause its arrest. 
Various morbid conditions, such as inflammatory adhesions, from old- 
standing peritonitis, pressing on the tube ; obstruction of its calibre 
by inspissated mucus or small polypoid growths; the pressure of 
uterine or other tumors, and the like, are supposed to have a similar 
effect. Tait 1 believes that the most important cause is chronic sal- 
pingitis, leading to destruction of the epithelium lining the tubes. 
The function of the epithelial cilia being to favor the progress of the 
ovum toward the uterus, when thev no longer exist the mucous lining 
of the tubes is reduced to a condition similar to that of the endo- 
metrium, and the ovum is apt to be arrested in transitu. Bland 
Sutton 2 admits this to be a possible although as yet an unproved 
explanation. The fact that extra-uterine pregnancies occur most fre- 
quently in multipara?, and comparatively rarely in women under thirty 
years of age, tends to show that these conditions, which are clearly 
more likely to be met with in such women than in young primiparse, 
have considerable influence in their causation. A curiously large 
proportion of cases occur in women who have either been previously 
altogether sterile, or in whom a long interval of time has elapsed since 
their last pregnancy. The disturbing effects of fright, either during 
coition or a few days afterward, have been insisted on by many authors 
as a possible cause. Numerous cases of this kind are recorded ; and, 
although the influence of emotion in the production of this condition 
is not susceptible of proof, it is not difficult to imagine that spasms of 
the Fallopian tubes might be produced in this way, which would either 
interfere with the passage of the ovum, or direct it into the abdominal 
cavity. The occurrence of abdominal pregnancy is probably less 
difficult to account for if we admit, with Coste, that the ovule may 
become impregnated on the surface of the ovary itself, for there must 
be very many conditions which prevent the proper adaptation of the 
fimbriated extremity of the tube to the surface of the ovary, and failing 
this the ovum must of necessity drop into the abdominal cavity. 
Kiwisch has pointed out that this is particularly apt to occur when 
the Graafian follicle develops on the posterior surface of the ovary ; 
and, indeed, it is probable that it may be of common occurrence 1 , and 
that the comparative rarity of abdominal pregnancy is due to the diffi- 

i Op. cit.,p. 4. 2 Op. cit., p. 309. 



182 PREGNANCY. 

culty with which the impregnated ovule engrafts itself on the sur- 
rounding viscera. Impregnation may actually occur in the abdominal 
cavity itself, of which Keller 1 relates a remarkable instance. In this 
case Koeberle had removed the body of the uterus and part of the 
cervix, leaving the ovaries. In the portion of the cervix that remained 
there was a fistulous aperture opening into the abdominal cavity, 
through which semen passed and produced an abdominal gestation. 
Several curious cases are also recorded, which have given rise to a 
good deal of discussion, in which a tubal pregnancy existed while the 
corpus luteum was on the opposite side (Fig. 82). The most probable 

Fig. 82. 




Tubal pregnancy, with the corpus luteum in the ovary of the opposite side. The decidua is 
represented in the process of detachment from the uterine cavity. 

explanation, however, is that the fimbriated extremity of the tube in 
which the ovum was found had twisted across the abdominal cavity 
and grasped the opposite ovary, in this way, perhaps, producing a 
flexion which impeded the progress of the ovum it had received into 
its canal. Tyler Smith suggested that such cases might be explained 
by supposing that the ovum, after reaching the uterus, failed to graft 
itself in the mucous membrane, but found its way into the opposite 
Fallopian tube. Kussmaul 2 thinks that such a passage of the ovum 
across the uterine cavity may be caused by muscular contraction of 
the uterus, occurring shortly after conception, squeezing the yet free 
ovum upward toward the opening of the opposite tube, and possibly 
into the tube itself. 

The history and progress of cases of extra-uterine pregnancy are 
materially different according to their site, and it is, therefore, neces- 
sarv to examine its varieties in detail. 

Tubal Pregnancies. — When the ovum is arrested in any part of 
the Fallopian tube the chorion soon commences to develop villi, just 
as in ordinary pregnancy, which engraft themselves into the mucous 
lining of the tube, and fix the ovum in its new position. The mucous 
membrane becomes hypertrophied, much in the same way as that of the 

1 Des Grossesses extra-uterlnes, Paris, 1872. 

2 Mon. f. Geburt., 1862, Bd. xx. S. 295. 



ABNORMAL PREGNANCY 



183 



uterus under similar circumstances, so that it becomes developed into a 
sort of pseudo-decidua, the uterine extremity of which has been observed 
to be open and in communication 
with the lining membrane of the ' '"• s:; 

uterus. 1 Inasmuch, however, as the 
mucous coat of the tubes is not fur- 
nished with tubular glands, a true 
decidua can scarcely be said to exist ; 
nor is there any growth of mem- 
brane around the ovum analogous 
to the decidua reflexa. The ovum 
is, therefore, comparatively speak- 
ing, loosely attached to its abnormal 
situation, and hence hemorrhage from 
laceration of the chorion villi can 
very readily take place. This leads 
to extravasation of blood between 
the villi, and it is often the determining cause of rupture, in conse- 
quence of the sudden increase in size of the tube contents. Should 
rupture not occur the ovum may be transformed into a fleshy mole, 
analogous to the uterine mole. 'And this is, doubtless, the origin of 
many cases of the so-called " hsemato-salpinx." The dependence of 
this on pregnancy may generally be proved by the tube contents show- 
ing chorionic villi on microscopical examination (Fig. 83). 

Tubal Abortion. — In some such cases the mole may afterward 
escape by rupture into the folds of the broad ligament, producing a 




Microscopical appearances of chorionic 
villi in transverse section from a tubal mole 
—low magnification. (After Bland Sutton.) 



Fig. 84. 




Tubal pregnancy. (From a specimen in the Museum of King's College.) 
i L. Bandl : Billroth's Handbuch der Frauenkrankheiten. 



184 



PREGNANCY 



hematocele, and these conditions have been described as "tubal 
abortion." 

It is seldom that any development of the chorion villi into distinct 
placental structure is observed ; this is probably owing to the fact that 
laceration and death generally occur before the period at which the 
placenta is normally formed. The muscular coat of the tube soon 
becomes hypertrophied, and as the size of the ovum increases the 
fibres are separated from each other, so that the ovum protrudes at 
certain points through them, and at these it is only covered by the 
stretched and attenuated mucous and peritoneal coats of the tube. At 
this time the tubal pregnancy forms a smooth oval tumor, which, as a 
rule, has not formed any adhesions to the surrounding structures 
(Fig. 84). The part of the tube unoccupied by the ovum may be 
found unaltered, and permeable in both directions ; or, more frequently, 
it becomes so stretched and altered that its canal cannot be detected. 
Most frequently it is that part of the tube nearest the uterus which 
cannot be made out. Sutton states that by the eighth week the abdom- 
inal extremity of the tube becomes obliterated by the protrusion of a 
ring of peritoneum around it, which gradually becomes occluded, and 
so hermetically closes the opening. 

FiGo 85. 




Interstitial or tubo-uterine pregnancy. (Guy's Hospital Museum. After Bland Sutton.) 



Condition of the Uterus. — The condition of the uterus in this, 
as in other forms of extra-uterine pregnancy, has been the subject of 
considerable discussion. It is now universally admitted that the uterus 



ABNORMAL PREGNANCY. 185 

undergoes a certain amount of sympathetic engorgement, the cervix 
become- softened, as in natural pregnancy, and the mucous membrane 

develops into a true decidua. In many cases the deeidua is found on 
post-mortem examination, in others it is not ; and hence the doubts 
that some have expressed as to its existence. The most reasonable 

explanation of its absence is that given by Duguet, 1 who has shown 
that it is far from uncommon for the uterine decidua to be thrown off 
en masse during the hemorrhagic discharges which so frequently pre- 
cede the fatal issue of extra-uterine gestation. 

Interstitial and False Ovarian Pregnancy. — When the ovum is 
arrested in that portion of the tube passing through the uterus, in 
so-called interstitial pregnancy (Fig. 85) the muscular fibres of the 
uterus become stretched and distended, and form the outer covering 
of the ovum. In this case rupture is delayed to a later date than in 
tubal pregnancy, but, when it occurs, hemorrhage is greater, in con- 
sequence of the thickness of the gestation sac, and the fatal issue is 
more certain and rapid. AVhen, on the other hand, the site of arrest 
is in the fimbriated extremity of the tube, the containing cyst is formed 
partly of the fimbriae of the tube, partly of ovarian tissue ; hence it 
is much more distensible, and the pregnancy may continue without 
laceration to a more advanced period, or even to term, so that when 
the ovuni is placed in this situation the case much more nearly resem- 
bles one of abdominal pregnancy. 

Progress and Termination. — The termination of tubal pregnancy, 
in the immense majority of cases, is death, produced by laceration 
giving rise either to internal hemorrhage or to subsequent intense 
peritonitis. Rupture usually occurs at an early period of pregnancy, 
most generally from the fourth to the twelfth week, rarely later. 
However, a few instances are recorded in which it did not take place 
until the fourth or fifth month, and Saxtorph and Spiegelberg have 
recorded apparently authentic cases in which the pregnancy advanced 
to term without laceration ; these were, however, probably examples 
of the sub-peritoneo-pelvic or abdominal varieties. It is generally 
effected by distention of the tube, which at last yields at the point 
which is most stretched ; and sometimes it seems to be hastened or 
determined by accidental circumstances, such as a blow or fall, or the 
excitement of sexual intercourse. 

Symptoms of Rupture. — The symptoms accompanying rupture 
are those of intense collapse, often associated with severe abdominal 
pain, produced by the laceration of the cyst. The patient will be 
found deadly pale, with a small, thready, and almost imperceptible 
pulse, perhaps vomiting, but with mental faculties clear. If the 
hemorrhage be considerable, she may die without any attempt at 
reaction. Sometimes, however — and this generally occurs in eases in 
which the tube tears, the ovum remaining intact — the hemorrhage 
may cease on account of the ovum protruding through the aperture 
and acting as a plug. The patient may then imperfectly rally, to be 
again prostrated by a second escape of blood, which proves fatal. If 

1 Annales de Gynecologie, 1874, torn. i. p. 269. 



186 



PREGNANCY. 



the loss of blood is not of itself sufficient to cause death from shock 
and anaemia, the fatal issue is generally only postponed, for the effused 
blood soon sets up a violent general peritonitis, which rapidly carries 
off the patient. This is the general course of events in the most 
common class of cases, in which the rupture involves the peritoneal 
surface of the tube. The hemorrhage then takes place directly into 
the peritoneal cavity, and, unless celiotomy is performed, is most 
usually fatal. 

Fig. 86. 




Extra-uterine pregnancy at term of the secondary abdominal variety. (After a case of 
Dr. A. Sibley Campbell's.) 



In the minority of cases of rupture, the proportion being given by 
Sutton as 1 to 3, the laceration takes place in that part of the tube 
which is not covered with peritoneum, that is, the under surface of 
the middle third of the tube. The blood then escapes into the con- 
nective tissue of the broad ligament, and is consequently extra- 
peritoneal. The space into which the blood can pour is much more 
limited than in the former case, and the results are less uniformly 
disastrous. If the ovum and the patient both survive the immediate 
rupture, the former continues to grow, and the case is transformed into 
one of sub-peritoneo-pelvic gestation. The case is then subjected to 
the rules of treatment presently to be discussed when considering 
secondary abdominal pregnancy. (Fig. 86.) 



ABNORMAL PREGNANCY. 187 

Diagnosis. — The possibility of diagnosing tubal gestation before 
rupture occurs is a question of great and increasing interest, from the 
fact that, could its existence be ascertained, we might very fairly hope 
to avert the almost certainly fatal issue which Is awaiting the patient. 
Unfortunately, the symptoms of tubal pregnancy are always obscure, 
and too often death occurs without the slightest suspicion as to the 
nature of the case having arisen. In the first place it is to be observed 
that all the usual sympathetic disturbances of pregnancy exist: the 
breasts enlarge, the areolae darken, and morning sickness is present. 
There is also an arrest of menstruation ; but, after the absence of one 
or more periods, tliere is often an irregular hemorrhagic; discharge. 
This is an important symptom, the value of which in indicating the 
existence of tubal pregnancy has of late years been much dwelt upon 
by various authors, both in this country and abroad. It may probably 
be 'attributed to partial detachment of the chorion villi, produced by 
the ovum growing out of proportion to the tube in which it is con- 
tained. Whether this is the correct explanation or not, it is a fact 
that irregular hemorrhage very generally precedes the laceration for 
several days or more. Associated with the hemorrhage there may 
occasionally be found shreds of the decidual lining of the uterus, the 
presence of which would materially aid the diagnosis. Accompanying 
this hemorrhage there is almost always more or less abdominal pain, 
produced by the stretching of the tissues in which the ovum is placed, 
and this is sometimes described as being of very intense and crampv 
character. If, then, we meet with a case in which the symptoms of 
early pregnancy exist, in which there are irregular losses of blood, 
possibly discharge of membranous shreds, and abdominal pain, a care- 
ful examination should be insisted on, and then the true nature of the 
case may possibly be ascertained. Should extra-uterine foetation exist, 
we should expect to find the uterus somewhat enlarged, and the cervix 
softened, as in early pregnancy, but both these changes are doubtless 
generally less marked than in normal pregnancy. This fact of itself, 
however, is of little diagnostic value, for slight differences of this kind 
must always be too indefinite to justify a positive opinion. 

The existence of a peri-uterine tumor, rounded or oval in outline, 
and producing more or less displacement of the uterus, in the direction 
opposite to that in which the tumor is situated, may point to the exist- 
ence of tubular foetation. By bimanual examination, one hand de- 
pressing the abdominal wall, while the examining finger of the other 
acts in concert with it either through the vagina or rectum, the size 
and relations of the growth may be made out. There are various 
conditions which give rise to very similar physical signs, such as small 
ovarian or fibroid growths, or the effusion of blood around the uterus ; 
and the differential diagnosis must always be very difficult and often 
impossible. A curious example of the difficulty of diagnosis is re- 
corded by Joulin, in which Huguier and six or seven of the most 
skilled obstetricians of Paris agreed on the existence of extra-uterine 
pregnancy, and had, in consultation, sanctioned an operation, when 
the case terminated by abortion, and proved to be a natural pregnancy. 
The use of the uterine sound, which might aid in clearing up the ease, 



188 PREGNANCY. 

is necessarily contra-indicated unless uterine gestation is certainly dis- 
proved. Hence it must be admitted that positive diagnosis must 
always be very difficult. So that the most we can say is, that when 
the general signs of early pregnancy are present, associated with the 
other symptoms and signs alluded to, the suspicion of tubal preg- 
nancy may be sufficiently strong to justify us in taking such action as 
may possibly spare the patient the necessarily fatal consequence of 
rupture. 

Treatment. — If the diagnosis were quite certain, the removal of the 
entire Fallopian tube and its contents by abdominal section would be 
quite justifiable, and would neither be more difficult nor more danger- 
ous than ovariotomy ; for, at this stage of extra-uterine foetation, there 
are no adhesions to complicate the operation. This operation has been 
performed in many cases with a most happy result, and there can be 
no doubt that in the hands of an operator sufficiently expert in abdom- 
inal surgery, it is the proper course to adopt, whenever the symptoms 
are sufficiently well marked to indicate its necessity. 

It is to be observed, however, that the uncertainty in the diagnosis 
in cases of this kind is very great, and it requires a good deal of ex- 
perience and self-reliance to enable the practitioner to adopt so radical 
a procedure. It is not surprising, therefore, that many expedients 
have been suggested and tried for arresting the growth of the ovum, 
and thus leaving it quiescent in the tube. Many cases have been 
recorded in which the issue has been supposed to be satisfactory. 
Whether they were so in fact, or whether the diagnosis was erroneous, 
as the opponents of such procedures are so apt to suggest, cannot, of 
course, be proved in the nature of things. Such procedures are char- 
acterized by Tait as " mere nonsense, m and by Sutton as so unsatis- 
factory as not to merit discussion. It must be fully admitted that 
cceliotomy in competent hands is infinitely more satisfactory, and it 
may be confidently recommended in every case in which the diagnosis 
is sufficiently plaiu. There will always, however, be a certain number 
of cases in which, either from the surroundings, the want of assistance 
or instruments, or of sufficient surgical aptitude on the part of the 
medical attendant, such radical measures cannot be adopted, and, there- 
fore, the methods referred to seem worthy of consideration. 

Dr. Thomas, of New York, 2 has recorded a most instructive case, in 
which he saved the life of the patient by a bold operation. The nature 
of the case was rendered pretty evident by the signs above described, 
and Thomas opened the cyst from the vagina by a platinum knife, 
rendered incandescent by a galvanic battery, by which means he hoped 
to prevent hemorrhage. Through the opening thus made he removed 
the foetus. In subsequently attempting to remove the placenta very 
violent hemorrhage took place, which was only arrested by injecting 
the cyst with a solution of persulphate of iron. The remains of the 
placenta subsequently came away piecemeal, after an attack of septi- 
caemia, which was kept within bounds by freely washing out the cyst 
with antiseptic lotion, the patient eventually recovering. Should this 

1 Op. cit. , p. 53. 

2 Xew York Med. Journ., 1875, vol. xxi. p. 561. 



ABNORMAL PREGNANCY. L89 

operation be resorted to, it would be better Dot to remove tlio placenta, 
but to plug the gestation sac with antiseptic gauze, frequently changed, 
and trust to antiseptic injections and thorough drainage to prevent 
septic mischief. This procedure has not, bo far as I know, been again 
adopted; the operation seems as severe and difficult as coeliotomy, 
which would be, in every way, preferable. 

Means of Destroying- the Vitality of the Foetus. — Another 
mode of managing these cases is to destroy the foetus, so as to check 
its further growth, in the hope that it may remain inert and passive 
within its sac. Various operations have been suggested and practised 
for this purpose. Thus needles have been introduced into the tumor, 
through which currents of electricity have been passed, either the con- 
tinuous current, or, as has been suggested by Duchenne, a spark of 
franklinic electricity. Hicks and others have endeavored to destroy 
the foetus by passing an electro-magnetic current through it by means 
of a needle. Of late years a large number of carefully recorded cases 
have been published, chiefly in America, in which the faradic current 
has been used, apparently with perfect success, one pole being passed 
through the rectum or vagina to the side of the ovum, the other being 
placed on a point in the abdominal wall two or three inches above 
Poupart's ligament ; or Apostoli's vaginal electrode, in which both 
poles are combined, might be used. The number of cases is so con- 
siderable 1 that it is quite futile to talk of this plan as " mere non- 
sense,'' or unworthy of consideration. On the contrary, under the 
conditions already mentioned, when coeliotomy is not feasible, it 
appears to offer a very hopeful resource. The current should be passed 
daily for at least ten minutes, and continued for a week or two until 
the shrinking of the tumor gives satisfactory evidence of the death of 
the fcetus. This practice is perfectly safe, and there can be no rational 
objection to its being tried. Aveling makes the reasonable suggestion 
that the current acts by producing " tetanic contractions of the foetal 
heart due to the repeatedly broken current of an induction machine." 2 
Simple puncture of the cyst has been successfully practised on several 
occasions, either with a small trocar and canula, or with a simple 
needle. A very interesting case, in which the development of a two 
months' tubal gestation was arrested in this way, is recorded by 
Greenhalgh, 3 and another by Martin, of Berlin. 4 Joulin suggested 
that not only should the cyst be punctured, but that a solution of 
morphine should be injected into it, which, by its toxic influence, 
would insure the destruction of the foetus; and this is probably one 
of the best means at our disposal for destroying the fcetus. Friedreich 
and others have reported successful cases, one-fifth of a grain of mor- 
phine being injected into the sac every second day, until it had 
obviously begun to shrink. 

Other means proposed for effecting the same object, such as pressure, 
or the administration of toxic remedies by the mouth, are far too un- 
certain to be relied on. The simplest and most effectual plan would 

1 See various papers in the Trans, of the Amer. Gyn. Soe. : also Lusk's Midwifery. 1892. 

2 "The Diagnosis and Electrical Treatment of Early Extra-uterine Gestation," Brit. Gyn. Journ., 
1888-S«.». vol. iv.p. 24. 

3 Lancet, 1867. 4 Monat. f. Geburt., 1868, Bd. xxxii. S. 110. 



190 PREGNANCY. 

be to introduce the needle of an aspirator, by which the liquor ainnii 
would be drawn off, and the further growth of the foetus effectually 
prevented. Parry, 1 indeed, is opposed to this practice, and has col- 
lected several cases in which the puncture of the cyst was followed by 
fatal results, either from hemorrhage or septicaemia. In these, how- 
ever, an ordinary trocar and canula were probably employed, which 
would necessarily admit air into the sac. It is difficult to imagine 
that a line hair-like aspirating needle, rendered perfectly aseptic by 
carbolic acid, could have any injurious results; and it could do no 
harm, even if an error of diagnosis had been made, and the suspected 
extra-uterine fcetation turned out to be some other sort of growth. If 
the aspirator proves that an extra-uterine fcetation exists, then, if the 
cyst be of any considerable size, and the pregnancy advanced beyond 
the second month, we might, if deemed advisable, resort to a more 
radical operation. 

Treatment when Rupture has Occurred. — TThen the chance of 
arresting the growth of a tubular fcetation has never arisen, and we 
first recognize its existence after laceration has occurred, and the patient 
is collapsed from hemorrhage, what course are Ave to pursue ? Hitherto 
all that has generally been done is to attempt to rally the patient by 
stimulants, and, in the unlikely event of her surviving the immediate 
effects of laceration, endeavoring to control the subsequent peritonitis, 
in the hope that the effused blood may become absorbed, as in pelvic 
hematocele. This is, indeed, a frail reed to rest upon, and when lacera- 
tion of a tubal gestation, advanced beyond a month, has occurred, 
death has been the almost certain result. It is now universally ad- 
mitted that in such cases practically the only hope for the patient lies 
in the immediate performance of cceliotomy, the rapid clearing away 
of the effused blood, and the search for, and ligature of, the ruptured 
tube. Mr. Lawson Tait's brilliant record of 42 cases, 39 of which 
recovered, would alone prove this to be, beyond any question, the 
proper, and indeed the only possible, practice, and happily many others 
are now able to record similar results. In these cases, in which rup- 
ture is never delayed beyond the twelfth or thirteenth week of gesta- 
tion, there are rarely any adhesions, and the operation presents no 
particular difficulty. As a rule, death does not follow rupture for 
some hours, so that there would be usually time for the operation, and 
the extreme prostration might be, perhaps, temporarily counteracted 
by saline transfusion. Pressure on the abdominal aorta, resorted to 
when the patient is first seen, might possibly be employed with advan- 
tage to check further hemorrhage, until the question of operation is 
decided. AVe must remember that the alternative is death, and hence 
any operation which Avould afford the slightest hope of success would 
be perfectly justifiable. 

In the second class of cases, in which the rupture is extra-peritoneal, 
the necessity for immediate operation is not so urgent. Cases of this 
kind are not so intense in their character, and they rally much more 
completely ; if they do so, it will doubtless be best not to interfere 
until a later date. 

1 Parry on Extra-nrerine Pregnancy, p. 204. 



A B N O R M A L V BEG N A N < Y . 



191 



Abdominal Pregnancy. — In the second of the two classes into 
which, for practical convenience, we have divided extra-uterine 
tton, the ovum is developed in the abdominal cavity. Jt is, as we 
have seen, very questionable it' there is such a condition a- primary 
abdominal pregnancy. Practically we may consider all the cases in 
which the foetus has developed in the abdominal cavity to have been 
primarily tubal or interstitial. Either the tube lias burst into the 
peritoneum at a very early period of pregnancy, and the ovum has 
maintained its vitality, or, more commonly, there has been an extra- 
peritoneal rupture, and subsequently the gestation sac has again given 
way, and the foetus has found its way into the abdominal cavity. 



Fig. 87 




Uterus and foetus in a case of abdominal pregnancy. 

Formation of a Cyst around the Ovum. — In the large majoritv 
of cases the ovurn produces considerable irritation, resnlting in the 
exudation of plastic material, which is thrown around it, so as to form 
a secondary cyst or capsule, in which maternal vessels are largely 
developed, and which stretches, pari passu, with the growth of the 
ovum (Fig. 87). This may be partly composed of remnants of rup- 
tured tube, and of the layers of the broad ligament, and to its external 
surface portions of intestine and omentum are frequently adherent. 
The placenta may be variously attached ; sometimes above the fetus 
at the upper part of the sac, sometimes below it, or partially to some 
of the adjacent abdominal viscera. The density and strength of this 
cyst are found to be very different in different cases ; sometimes it 
forms a complete and strong covering to the ovum, at others it is very 
thin and only partially developed, but it is rarely entirely absent. As 
there is ample space for the development of the ovum, and as the 
secondarv cyst wnerallv stretches and grows alono; with it, most cases 
of abdominal pregnancy progn — without any very remarkable symp- 
toms beyond occasional severe attacks of pain, until the full term of 
pregnancy has been reached. Sometime-, however, the cyst lacerate-, 
and there is an escape of blood into the abdominal cavity, accompanied 



192 



PKEGNANCY, 



by more or less prostration and collapse, which may prove fatal, but 
from which the patient more generally rallies. The foetus, now dead, 
will remain in the abdomen, and will undergo changes and produce 
results similar to those which we shall presently describe as occurring 
in cases progressing to the full period. 

In most cases, at the natural termination of pregnancy a strange 
series of phenomena occur ; pseudo-labor comes on, there are more or 
less frequent and strong uterine contractions, possibly an escape of 
blood from the vagina, the discharge of the broken-down uterine 
decidua, and even the establishment of lactation. Sometimes the con- 
tractions of the abdominal muscles produced by this ineffective labor 
have been so strong as to cause the laceration of the adventitious cyst 
surrouding the foetus, and the escape of blood and liquor amnii into 
the abdominal cavity, with a rapidly fatal result. More frequently 
laceration does not occur, and the spurious labor-pains continue at 
intervals, until the foetus dies, possibly from pressure, but more often 
from effusion of blood into the tissue of the placenta, and consequent 
asphyxia. Occasionally the foetus has apparently lived a considerable 
time, in some cases even for several months, after the natural limit of 
pregnancy has been reached. 

Changes after the Death of the Foetus. — It is after the death of 
the foetus that the dangers of abdominal pregnancy generally com- 
mence, and they are numerous and various. The subsequent changes 
that occur are well worthy of study. Occasionally the foetus has been 
retained for a length of time, even until the end of a long life, without 

producing any serious discomfort, and in 
many cases of this kind several normal 
pregnancies and deliveries have subse- 
quently taken place. Even when the 
extra-uterine gestation appears to be tol- 
erated, and has remained for long without 
producing any bad effects, serious symp- 
toms may be suddenly developed ; so that 
no woman, under such circumstances, can 
be considered safe. The condition of 
these retained foetuses varies much. Most 
commonly the liquor amnii is absorbed, 
the foetus shrinks and dies, all its soft 
structures are changed into adipocere, and 
the bones only remain unaltered. Some- 
times this change occurs with great rapid- 
ity. I have elsewhere 1 recorded a case of 
extra-uterine foetation in Avhich at the full 
term of pregnancy the foetus was alive, 
and the woman died in less than a year 
afterward. On post-mortem examination 
the foetus was found entirely transformed into a greasy mass of adi- 
pocere, studded with foetal bones, in which not a trace of any of the 



Fig. 88. 




Lithopsedion. (From a preparation 
in the Museum of the College of Sur- 
geons) 



i Obst. Trans., 1S65, vol. vii. p. 1. 



ABNORMAL PREGNANCY. 198 

soft parts could be detected. ( >n the other hand, the foetus may remain 
unchanged; in the Museum of the College of Surgeons there ig one 
which was retained in the abdomen for fifty-two year-, and which was 
found to be as fresh and unaltered as a newborn child. In other cases 
the sao and its contents atrophy and shrink, and calcareous matter is 
deposited in them, so that die whole becomes converted into a solid 
mass known as lithopcedion (Fig. 88). The cases, however, in which 
the retention of the foetus gives rise to no mischief are quite excep- 
tional. Generally the foetus putrefies, and this may either immediately 
cause fatal peritonitis or septicaemia, or, as more commonly happen-, 
secondary inflammation and suppuration of the sac. Under the influ- 
ence ofthe latter the sac opens externally, either directly at -Mine point 
of the abdominal walls, or indirectly through the vagina, the bowels, or 
even the bladder. Through the aperture or apertures thus formed (for 
there are often several fistulous openings), pus, and the bones and other 
parts of the broken-down foetus are discharged ; and this may go on 
for months, and even years, until at last, if the patient's strength does 
not give way, the whole contents ofthe cyst are expelled, and recovery 
takes place. From various statistical observations it appears that the 
chances of recovery are best when the cyst opens through the abdom- 
inal walls, next through the vagina or bladder, and that the foetus is 
discharged with most difficulty and danger when the aperture is formed 
into the bowel. At the best, however, the process is long, tedious, and 
full of danger ; and the patient too often sinks, during the attempt at 
expulsion, through the irritation and exhaustion produced by the abun- 
dant and long-continued discharge. 

Diagnosis. — The diagnosis of abdominal gestation is by no means 
so easy as might be thought, and the most experienced practitioners 
have been mistaken with regard to it. 

The most characteristic symptom, although this is not so common as 
in tubal gestation, is metrorrhagia combined with the general signs of 
pregnancy. Very severe and frequently repeated attacks of abdominal 
pain are rarely absent, and should at once cause suspicion, especially if 
associated with hemorrhage, and the discharge of a decidual membrane 
from the uterus. They are supposed by some to depend on inter- 
current attacks of peritonitis, by which the foetal cyst is formed. Parry 
doubts this explanation, and attributes them partly to the distention 
of the cyst by the growing foetus, and partly to pressure on the sur- 
rounding structures. On palpation the form of the abdomen will be 
observed to differ from that of normal pregnancy, being generally 
more developed in the transverse direction, and the rounded outline of 
the gravid uterus cannot be detected. When development has advanced 
nearly to term, the extreme distinctness with which the foetal limbs 
can be felt will arouse suspicion. Per vaginam the os and cervix will 
be felt softened, as in ordinary pregnancy, but often displaced by the 
pr<— ure of the cyst, and sometimes fixed by peri-metritic adhesions; 
either of these signs is of great diagnostic value. 

By bimanual examination it may be possible to make out that the 
uterus i- not greatly enlarged, and that it i- distinctly separate from 
the bulk of the tumor : these facts, if recognized, would of themselves 

13 



194 PREGNANCY. 

disprove the existence of uterine gestation. The diagnosis, if the 
foetal limbs or heart-sounds could be detected, would be cleared up in 
any case by the uterine sound, which would show that the uterus was 
empty and only slightly elongated. But we must be careful not to 
resort to this test unless the existence of uterine gestation is positively 
disproved by other means. As, however, it places the diagnosis beyond 
a doubt, it should always- be employed whenever operative procedure 
is in contemplation. Quite recently I have seen a remarkable case 
which illustrates the importance of this rule. The case had been 
diagnosed as abdominal pregnancy by no fewer than six experienced 
practitioners, and was actually on the operating-table for the per- 
formance of cceliotomy. As a precaution, having some doubts of the 
diagnosis, I suggested the passage of the sound, which entered into a 
gravid uterus, the case proving to be one of small ovarian tumor 
jammed down into Douglas' space, and displacing the cervix forward. 
Had it not been for this precaution its true nature would certainly not 
have been detected. 

Treatment. — The treatment of abdominal gestation will always be 
a subject of anxious consideration, and there is much difference of 
opinion as to the proper course to pursue. It is becoming more 
generally recognized as good practice, that when the existence of an 
abdominal pregnancy is thoroughly established, no matter what the 
period of pregnancy, the sooner it is operated on the better. Punc- 
turing the cyst, with the view of destroying the foetus and arresting its 
further growth, has been practised, but there are good grounds for 
rejecting it, for there is not the same imminent risk of death from rup- 
ture of the cyst as in tubal foetation ; and, even if the destruction of the 
foetus could be brought about, there would still be formidable dangers 
from subsequent attempts at elimination, or from internal hemorrhage. 

If we have to deal with a case which has advanced nearly to the full 
period, the child being still alive, as proved by auscultation, we have 
to consider whether it may not be advisable to perform coeliotomy 
before the foetus perishes, and so at least save the life of the child. 
There are few questions of greater importance and more difficult to 
settle. The tendency of medical opinion is decidedly in favor of 
immediate operation, which is recommended by Velpeau, Kiwisch, 
Koeberle, Schroeder, Tait, and many other writers, whose opinion 
necessarily carries great weight. The arguments used in favor of im- 
mediate operation are that while it affords a probability of saving the 
child, the risks to the mother, great though they undoubtedly are, are 
not greater than those which may be anticipated by delay. If we put 
off interference the cyst may rupture during the ineffectual efforts at 
labor, and death at once ensue ; or, if this does not take place, other 
risks, which can never be foreseen, are always in store for the patient. 
She may sink from peritonitis, or from exhaustion, consequent on the 
efforts at elimination, which in the majority of cases are sooner or later 
set up, so that, as Barnes properly says, " the patient's life may be said 
to be at the mercy of accidents of which we have no sufficient warn- 
ing." On the other hand, if Ave delay, while we sacrifice all hope of 
saving the child, we at least give the mother the chance of the foetation 



ABNORMAL PREGNANCY. 195 

remaining quiescent for a length of time, as certainly do1 unfrequently 
(.(•cur-. Thus, Campbell collected 62 cases of ultimate recovery after 
abdominal gestation, in 21 of which the foetus was retained without 
injury for a number of years. Then there is the question of secondary 
celiotomy, which consists in operating after the death of the foetus 
when urgent symptoms have arisen, a course which is advocated by 
Mr. Hutchinson. In favor of this procedure it is urged that by delay 
the inflammation taking place about the cyst will have greatly incr 
the chance ^^t' adhesions having formed between it and the abdominal 
parietes. so as to shut off its contents from the cavity of the peri- 
toneum. The more effectually this has been accomplished, the greater 
are the chances of recovery. AVhen the foetus has been dead for some 
time, the vascularity of the cyst will also be lessened, the placental 
circulation will have ceased, and that viscus will have become solid 
and tough, so that the danger of hemorrhage will be much diminished. 

It will be seen, therefore, that there are arguments in favor of each 
of these views. The results of the primary operation are far less favor- 
able than we should have, a priori, supposed. Since the first edition of 
this work appeared the subject has been carefully studied by Dr. Parry 
in his exhaustive treatise on Extra-uterine Fcetation. He has there shown 
that when the case is left until Nature has shown the channel through 
which elimination is to be effected, the mortality is 17.35 per cent, 
less than in the cases in which the primary operation was per- 
formed. His conclusion is that " the primary operation cannot be too 
forcibly condemned. It is not too much to say that this operation 
adds only another danger to a life already trembling in the balance, 
which the delusive hope of saving the uncertain life of a child does 
not warrant tis in assuming. 7 ' It is only just to remember, however, 
that in these days of advanced abdominal surgery a better result mav 
be anticipated than when eceliotomy was performed in the haphazard 
way which was usual before we had gained experience from ovariotomv. 
Xo doubt, minute care in the performance of the operation, a due atten- 
tion to its details, studiously avoiding, as much as possible, the passage 
of blood and the contents of the cyst into the peritoneal cavity, and a 
free use of antiseptics, will materially lessen its peril. 

Mode of Performing" the Operation. — The operation should be 
performed with all the precautions with which Ave surround ovari- 
otomy. The incision, best made in the linea alba, should not be 
greater than is necessary to extract the foetus, and may be lengthened 
as occasion requires. If there are no adhesions, the Avails of the cyst 
should be stitched to the margin of the incision, so as to shut it off as 
completely as possible from the peritoneal cavity. This has been 
specially insisted on by Braxton Hicks, and should never be omitted. 
The special risk is not so much the'Avounding of the peritoneum as 
the subsequent entrance of septic matter from the cyst into its cavity. 
It has been laid down as a rule that after incising the sac no attempt 
should be made to remove the placenta. Its attachments are generally 
so deep-seated and diffused that any endeavor to separate it is likely 
to be attended with profuse and uncontrollable hemorrhage, or with 
serious injury to the structures to which it is attached. Many of the 



196 PREGNANCY. 

failures after operating can be traced to a neglect of this rule. The 
best subsequent course to pursue, after removing the foetus and arrest- 
ing all hemorrhage, either by ligature or the actual cautery, is to 
sponge out the cyst as gently as possible, sprinkle the cavity with 
iodoform, or with equal parts of tannin and salicylic acid, as recom- 
mended by Freund, 1 and then to bring the upper part of the wound 
into apposition with sutures, leaving the lower open, so as to insure 
an outlet for the escape of the placenta as it slips down. The subse- 
quent treatment must be specially directed to favor the escape of the 
discharge, and to prevent the risk of septicaemia. These objects mav 
be much aided by injections of antiseptic fluids, such as solution 
of carbolic acid, or creolin and water; and it would probably be 
advisable to place a drainage-tube in the lower angle of the wound. 

As long as the placenta is retained the danger is necessarily great, 
and it may be many days, or even weeks, before it is discharged. 
AVhen once this is effected the sac may be expected to contract, and 
eventually to close entirely. 

Excision of the Cyst. — The more advanced school of operators 
have of late years advised the complete excision of the sac and placenta, 
especially in the primary operation, a procedure which would probably 
be more feasible when gestation has not advanced to term. This has 
been the course adopted with considerable success by Martin, of 
Berlin, Breisky, of Vienna, and others. In this operation, after re- 
moving the foetus, the gestation sac and placenta has been ligatured, 
bit by bit, and removed, without any attempt at tearing or separating 
the placenta, and thus the uncontrollable hemorrhage, which has been 
so serious a danger when the placenta is interfered with, is avoided. 
It is needless to point out that such a procedure is only likely to 
succeed in the hands of operators thoroughly self-reliant and conver- 
sant with the details of abdominal surgery. Under such conditions, 
since it materially lessens the risk of septic infection, which must 
always be excessive when the cyst and placenta remain in the abdomen, 
it is clearly the most hopeful resource, and it is by some such operation 
as this that, in future, cases of primary operation will be dealt with. 

Treatment. — "When the foetus is dead, or when we have determined 
not to attempt primary coeliotomy, it is advisable to wait, very care- 
fully watching the patient, until either the gravity of her general 
symptoms, or some positive indication of the channel through which 
Nature is about to attempt to eliminate the foetus, shows us that 
the time for action has arrived. If there be distinct bulging of the 
cyst in the vagina, or in the retro-uterine cul-de-sac, especially if an 
opening has formed there, we may properly content ourselves with 
aiding the passage of the foetus through the channel thus indicated, 
and removing the parts that present piecemeal as they come within 
reach, cautiously enlarging the aperture if necessary. If the sac have 
opened into the intestines, the expulsion of the foetus through this 
channel is so tedious and difficult, the exhaustion attending it so 
likely to prove fatal, and the danger from decomposition of the foetus 

i Edin. Med. Journ., vol. 1SS3-S4, p. 521. 



ABNORMAL P R E G N A NCV. 1 '. <7 

through passage of intestinal gas bo great, that it would probably be 
best to attempt to remove it by cceliotomy, especially it' it is only 
recently dead, and the greater portion is -till retained. 

Mode of Performing- Secondary Cceliotomy. — If an opening 
forms in the abdominal parietes, or if the symptoms determine ua to 
resort to secondary coeliotomy before this occurs, the operation must 
be performed in the same way, and with the same precautions as 
primary coeliotomy. This operation is not only more simple, but 
much more successful than the primary. Bland Sutton 1 giv< - a list of 
seven cases operated on after the death of the foetus at or mar term, in 
all of which the mothers recovered. This is doubtless due to changes 
in the placental circulation, which renders its connections much less 
vascular and facilitate its separation, and these are believed to be 
completed about ten weeks after foetal death, so that the operation 
should be postponed, if possible, until that time has elapsed after the 
supposed death of the child. The placenta should be left to exfoliate 
spontaneously, and the cavity of the sac treated as after the primary 
operation. Here, as before, the safety of the operation must greatly 
depend on the amount and firmness of the adhesions : for if the cyst 
be not completely shut otf from the peritoneal cavity, the risks of the 
operation will be little less than those of primary cceliotomy. It 
would obviously materially influence our decision and prognosis if we 
could determine this point before operating. Unfortunately it is 
impossible, as the experience of ovariotonusts proves, to ascertain the 
existence of adhesions with any certainty. If, however, we find that 
the abdominal parietes do not move freely over the cyst, and if the 
umbilicus be depressed and immovable, the presumption is that con- 
siderable adhesions exist. If they are found not to be present, the 
cyst walls should be stitched to the margin of the incision, in the 
manner already indicated, before the contents are removed. 

If the fcetus has been long dead, and its tissues greatly altered, its 
removal may be a matter of difficulty. In the case under my own 
care, already alluded to, the fcetal structures formed a sticky mass of 
such a nature that I believe it would have been impossible to empty 
the cyst had an operation been attempted. This would be, to some 
extent, a further argument in favor of the primary operation. 

Opening- of Cyst by Caustics. — The importance of adhesions has 
led some practitioners to recommend the opening of the cyst by potassa 
fiisa or some other caustic, in the hope that it would set up adhesive 
inflammation around the aperture thus formed. Several successful 
operations by this method are recorded, and it would be worth trying, 
should the extreme mobility of the cyst lead us to suspect that no 
adhesions existed. If we have to deal with a case in which fistulous 
openings leading to the cyst have already formed, it may, perhaps, be 
advisable to dilate the apertures already existing, rather than make a 
fresh incision ; but, in determining this point, the surgeon will 
naturally be guided by the nature of the case, and the character and 
direction of the fistulous openings. 

1 Op. cit., p. 425. 



198 PREGNANCY. 

General Treatment. — It is almost needless to say anthing of 
general treatment in these trying cases ; but the administration of 
opiates to allay the sufferings of the patient, and the endeavor to sup- 
port the severely taxed vital energies by appropriate food and medica- 
tion, will form a most important part of the management. Freund 
specially insists on the importance of careful regulation of the bowels, 
and on making milk the staple article of diet, as important points in 
the management of cases prior to operation. 

Gestation in a Bi-lobed Uterus. — A few words may be said as to 
gestation in the rudimentary horn of a bi-lobed uterus, to which con- 
siderable attention has of late years been directed by the writings of 
Kussmaul and others. It appears certain that many cases of supposed 
tubal gestation are really to be referred to this category. Although 
such cases are of interest pathologically, they scarcely require much 
discussion from a practical point of view, inasmuch as their history is 
pretty nearly identical with that of tubal pregnancy. The rudimentary 
horn is distended by the enlarging ovum, and after a time, when further 
distention is impossible, laceration takes place. As a matter of fact, all 
the thirteen cases collected by Kussmaul terminated in this way ; and 
even on post-mortem examination it is often extremely difficult to dis- 
tinguish them from tubal pregnancies. The best way of doing so is 
probably by observing the relations of the round ligament to the 
tumor ; for, if the gestation be tubal, it will be found attached to the 
uterus on the inner or uterine side of the cyst ; whereas, if the preg- 
nancy be in a rudimentary horn of the uterus, it will be pushed out- 
ward, and be external to the sac. In the latter case, moreover, the 
sac will be probably found to contain a true decidua, which is not the 
case in tubal pregnancy. The only point in which they differ is that 
in cornual pregnancy, rupture may be delayed to a somewhat later 
period than in tubal, on account of the greater distensibility of the 
supplementary horn. 

Missed Labor. — The term " 7nissed labor" is applied to an exceed- 
ingly rare class of cases in 'which, at the full period of pregnancy, 
labor has either not come on at all, or, having commenced, the pains 
have subsequently passed off, and the foetus is retained in utero for a 
very considerable length of time. Under such circumstances it has 
usually happened that the membranes have ruptured at or about the 
proper term, and the access of air to the foetus in utero has been followed 
by decomposition. A putrid and offensive discharge has then com- 
menced, and eventually portions of the disintegrating foetus have been 
expelled per vaginam. This discharge may go on until the entire foetus 
is gradually thrown off; or, more frequently the patient dies from sep- 
ticaemia, or other secondary result of the presence of the decomposing 
mass in utero. Thus McClintock relates one case, 1 in which symptoms 
of labor came on in a woman, forty-five years of age, at the expected 
period of delivery, but passed off without the expulsion of the foetus. 
For a period of sixty-seven weeks a highly offensive discharge came 
away, with some few bones, and she eventually died with symptoms 

1 Dublin Quarterly Journal, Feb. and May, 1864. 



ABNORMAL PREGNANCY 



199 



of pyaemia. He also cites another case in which the patienl died in 
the same way, after the foetus had been retained for eleven years. 

Sometimes when the foetus lias been retained for a Length of time, a 
further source of danger has been added by ulceration or destruction 
of the uterine walls, probably in consequence of an ineffectual attempt 
at its elimination. This occurred in Dr. Oldham's case (Fig. 8!)), in 
which the contained mass is said to have nearly worn through the 
anterior wall of the uterus; and also in one reported by Sir James 
Simpson, 1 in which a patient died three months after term, the foetus 
having undergone fatty metamorphosis, an opening the size of half-a- 
crown having formed between the transverse colon and the uterine 
cavity. It is also stated that " the uterine walls were as thin as 
parchment." 

Fig. 89. 




Contents of the cyst in Dr. Oldham's case of missed labor. 



In some few cases, however, probably when the entrance of air has 
been prevented, the foetus has been retained for a length of time with- 
out decomposing, and without giving rise to any troublesome symp- 
toms. Such a case is reported by Dr. Cheston, 2 in which the foetus 
remained in utero for fifty-two years. 

The causes of this strange occurrence are altogether unknown. 
Generally the foetus seems to have died some time before the proper 
term for labor, and this may have influenced the character of the 
pains. It is probably also most apt to occur in women of feeble and 
inert habit of bodv, possiblv where there was some obstacle to the 



i Edin. Med. Journal, 1861. 



Med.-Chir. Trans., 1814. 



200 PREGNANCY. 

dilatation of the cervix, which the pains were unable to overcome. 
Barnes suggests 1 that some presumed examples of missed labor " were 
really cases of interstitial gestation, or gestation in one horn of a two- 
horned uterus;" and Macdonald 2 recently recorded a very interesting 
case in which he performed coeliotomy for what he believed to be a 
uterine fibroid, but which turned out to be one horn of a bifurcated 
uterus containing a foetus which had been retained for more than a 
year. He believes that most, if not all, cases of " missed labor" are 
of this kind, delivery at term proving impossible because of the narrow 
connection between the impregnated horn and the cervix. 

Midler, of Nancy, has attempted to prove, by a critical examination 
of published cases, 3 that most examples of so-called " missed labor " 
were in reality cases of extra-uterine foetation, in which an ineffectual 
attempt at parturition took place, the foetus being subsequently re- 
tained. 

From what has been said, it will be seen that the dangers arising 
from this state are very considerable, and when once the full term has 
passed beyond doubt, especially if the presence of an offensive discharge 
shows that decomposition of the foetus has commenced, it would be 
proper practice to empty the uterus as soon as possible. The necessary 
precaution, however, is not to decide too quickly that the term has 
really passed ; and, therefore, we must either allow sufficient time to 
elapse to make it quite certain that the case really falls under this 
category, or have unequivocal signs of the death of the foetus, and 
injury to the mother's health. 

Treatment. — If we had to deal with the case before any extensive 
decomposition of the foetus had occurred, we probably should find little 
difficulty in its management, for the proper course then would be to 
dilate the cervix with fluid dilators, and remove the foetus by turning ; 
or, before doing so, we might endeavor to excite uterine action by 
pressure and ergot. If the case did not come under observation until 
disintegration of the foetus had begun, it would be more difficult to 
deal with. If the foetus had become so much broken up that it was 
being discharged in pieces, Dr. McClintock says that " in regard to 
treatment, our measures should consist mainly of palliatives, viz., rest 
and hip-baths, to subdue uterine irritation ; vaginal injections, to secure 
cleanliness and prevent excoriation ; occasional digital examination so 
as to detect any fragments of bone that might be presenting at the os, 
and to assist in removing them. These are plain rational measures, 
and beyond them we shall scarcely, perhaps, be justified in venturing. 
Nevertheless, under certain circumstances, I would not hesitate to dilate 
the cervical canal so as to permit of examining the interior of the womb, 
and of extracting any fragments of bone that may be easily accessible ; 
but unless they could thus be easily reached and removed, the safer 
course would be to defer, for the present, interfering with them." * 

It may be doubted, I think, whether, considering the serious results 
which are known to have followed so many cases, it would not, on the 

1 Diseases of Women, p. 445. 

2 Edin. Med. Journ., vol. 1884-85. p. 873. 

3 De la Grossesse uterine prolongee indefiniment, Paris, 1878. 

4 Dublin Quart. Journ., vol. xxxvii, p. 314. 



ABNORMAL PREGNANCY. 201 

whole, be safer to make at least one decided effort, under chloroform, 
to remove as much as possible of the putrefying uterine contents, after 

the os has been fully dilated. Such a procedure would be less irri- 
tating than frequently repeated endeavors to pick away detached por- 
tions of the foetus, as they present at the os uteri. When once the 
os is dilated, antiseptic intra-uterine injections might he Bafely and 
advantageously used. Unquestionably, it would be bett< r practice to 
interfere and empty the uterus as soon as we are quite satisfied of the 
nature of the case, rather than to delay until the Foetus has been dis- 
integrated. Macdonald thinks that abdominal section would be the 
best course to pursue, either removing the sac entire or resorting to 
Porro's operation. This advice is based on the assumption that 
''missed labor" is essentially the retention of a foetus in one horn 
of a bi-lobed uterus, a theory which certainly cannot yet be taken as 
]> roved. 

[Causes of " Missed Labor." — From several cases that have been 
reported in the United States we find that the failure of the uterus to 
expel its contents may be due to a variety of causes. If Ave are certain 
that the foetus is actually in utero, that there is no pelvic or vaginal 
obstruction, and that the uterus is itself of normal form, then we must 
look for the cause of difficulty in the organ itself. By an examination 
of our reports of Cesarean operations we find that there have been 
several cases in which the power of the uterine contractions was insuffi- 
cient to overcome the resistance to expansion in the cervix. This may 
be due either to a Avant of contractile force in the muscular coat, to a 
change in the tissues of the cervix as the result of inflammation, or to 
both conditions combined. Where the muscular power of the uterus 
is in its integrity, the resistance in the cervix may be such that the os 
may remain unchanged after it is slightly opened, and the patient con- 
tinue in labor until the contractile power of the uterus is exhausted, 
when all muscular contraction will cease. Efforts at expulsion may 
recur at intervals covering a period of many months, when they Avill 
cease finally. In two Cesarean cases in the United States, the subjects 
being black, there was found a calcareous incrustation over and around 
the internal os uteri. The first operation was performed in Virginia 
in 1828 upon a multipara of twenty-five. 1 She Avas taken in labor at 
term, and had pains for two or three days together, at intervals, for 
about four weeks, after which pains returned occasionally during fifteen 
mouths. The cervix admitted the index finger, and in time the foetus 
became putrid. When operated upon she had carried the foetus two 
years. There was very little hemorrhage in the operation, although 
the uterus failed to contract, and for this reason was sutured. The 
woman died in the second Aveek, of peritonitis, following an attack of 
indigestion, produced by a meal of animal food and cider. The second 
case, also a multipara, was operated upon in Georgia in 1877, after a 
labor of four days, by Dr. Theodore Starbuck, avIio describes the de- 
posit as " ossific." The child was dead, and the woman died of internal 



P Am. Journ Med. Sci., vol. xviii. p. 257.] [ 2 Communicated by the operator, 1SS0.] 



202 PKEGNANCY. 

In a third case, also black, the cause of retention appears to have 
been a prevention of the descent of the foetus, from its arm and leg 
being secured within the uterus. The woman was thirty-three years 
old aud the mother of one child, and was operated upon by Dr. J. C. 
Egan, of Shreveport, Louisiana, August 25, I860. 1 On May 4, 1857, 
while at work in the field, she felt a sudden and violent pain in the 
left side; fainted, remained insensible so long as to be thought dead, 
but finally revived, and was pronounced four months pregnant. Labor 
began in November ; the os dilated, head presented, but did not de- 
scend ; pains continued at intervals for a month. In the fall of 1858 
an abscess opened, leaving a fistula one and a quarter inches below the 
umbilicus. When operated upon nearly two years later, she was 
greatly emaciated and affected with hectic fever. The uterus being 
adherent, the peritoneal cavity was not opened. When the foetus was 
extracted, its left foot and hand were wanting, and, search being made, 
were found in a pouch on the left side of the uterus, enclosed by bands 
which were cut for their liberation. The uterus was examined biman- 
ually to make sure that the cervix was sufficiently open for drainage. 
The decomposed foetus had been carried thirty-three months after 
maturity. Dr. Egan believes that a partial rupture of the uterus 
took place at the time of her attack in the field, and that the arm and 
leg were caught in its partial cicatrization. The woman made a good 
recovery. 

Much light is thrown upon a possible way of accounting for some 
of the mysterious cases of missed labor, which have been claimed to be 
extra-uterine in order to account for them, by a case recently operated 
upon in Portland, Maine, by Dr. Stanley P. Warren, and kindly 
reported to me by letter. The woman was a native, of Scotch-Irish 
descent, aged thirty-two, and mother of a child of thirteen. She last 
menstruated in January, 1884. Supposed accidental abortion in May, 
as there was hemorrhage ; the physician said he had removed the 
placenta, and there was. a thick " molasses-like " discharge afterward. 
Dr. Warren was called in a week later ; found metro-peritonitis and a 
tumor of about four inches in diameter in the right groin. The peri- 
tonitis became general, and Dr. W. was in attendance for fifteen days. 
On July 1st the tumor was in the median line, and foetal movements 
and heart-sounds distinct. Labor expected about October 28th ; sub- 
sequent gestation normal. Was called October 26th, at 11 p.m.; 
found no true pains ; pains apparently abdominal, rather than uterine, 
and continuous in the back and over the sides of the uterus. Foetus 
transverse, with head to right; pulse 152. No change for several days. 
Second week in November found child dead. Next four weeks slight 
occasional chills, and temperature 102° for two or three nights, but 
usually normal. Absolutely no expulsive pains. Cervix reached with 
difficulty, and finger passed through a long tubular neck, but foetus 
not reached. Cervix absolutely closed from December 21st to 29th ; 
pulse 120, temperature 100° to 102°. Attempted to dilate with sponge 
tent, but could not pass it into the uterine cavity. December 30th 

[} N. O, Med. and Surg. Journ., July, 1877, p. 35 ; also communicated by operator, 1878.] 



DISEASES OF PREGNANCY. 203 

attempted to open cervix by digital dilatation, and succeeded finally 
in passings cranioclast, but the parts closed as soon as the dilators 
were removed. Patient in a profound shock. Alter stimulating for 
an hour, performed Cesarean section; hemorrhage Blight ; peritoneum 
adherent everywhere to uterus; uterine wall one-quarter inch thick; 
child presented by right arm and side; placenta thin and far advanced 
in fatty degeneration ; no hemorrhage on its removal ; uterus did not 
contract; sutured by continuous stitch with catgut. Child eight and 
a half pounds. Woman rallied slightly, but died of shock in twenty- 
eight hours. Drs. T. A. Foster and S. C. Gordon were associated 
with Dr. Warren in the management of the ease. 

It would appear in this instance of missed labor that the changes 
produced by metro-peritonitis prevented the natural dilatation of the 
cervix and the contractile action of the muscular coat of the uterus 
Possibly, fatty degeneration of the muscular fibres bad taken place, 
but this could not be ascertained, as there was no autopsy. 

The Cesarean ease of Dr. Brodie S. Herndon, of Fredericksburg, 
Virginia, operated upon with success in 1845, bears a close resemblance 
in many of its features to that of Dr. Warren. The subject was a 
white multipara of thirty, whose pains of labor gave place to the con- 
tinuous pain and other characteristic symptoms of peritonitis. This 
disease lasted a month, during which time the fluid contents of the 
uterus escaped and the vaginal discharge became very offensive. Five 
weeks after the peritonitis commenced the os uteri admitted two fingers, 
and attempts at dilatation were made, but failed. Under ergot an 
offensive placenta was expelled, but the foetus could not be removed. 
The woman being greatly wasted and her room filled with stench, the 
Cesarean operation was performed on November 16th, forty-six days 
after the first signs of labor appeared. The uterus being adherent, the 
peritoneal cavity was not exposed ; the uterus was sponged out, but did 
not contract; it was closed in the suturing of the abdomen. The 
patient made a good recovery. As in the Warren case, the uterus 
became unsuited for performing the functions of labor by reason of 
changes in its tissues effected by inflammatory action. — Ed.] 



CHAPTEE YII. 

DISEASES OF PKEGNANCY. 

The diseases of pregnancy form a subject so extensive that they 
might well of themselves furnish ample material for a separate treatise. 
The pregnant woman is, of course, liable to the same diseases as the 
non-pregnant ; but it is only necessary to allude to those whose course 



204 PREGNANCY. 

and effects are essentially modified by the existence of pregnancy, or 
which have some peculiar effect on the patient in consequence of her 
condition. There are, moreover, many disorders which can be dis- 
tinctly traced to the existence of pregnancy. Some of them are the 
direct results of the sympathetic irritations which are then so commonly 
observed ; and, of these, several are only exaggerations of irritations 
which may be said to be normal accompaniments of gestation. These 
functional derangements may be classed under the head of neuroses, 
and they are sometimes so slight as merely to cause temporary incon- 
venience, at others so grave as seriously to imperil the life of the 
patient. Another class of disorders is to be traced to local causes in 
connection with the gravid uterus, and are either the mechanical 
results of pressure, or of some displacement or morbid state of the 
uterus ; while the origin of others may be said to be complex, being 
partly due to sympathetic irritation, partly to pressure, and partly to 
obscure nutritive changes produced by the pregnant state. 

Derangements of the Digestive System. — Among the sympa- 
thetic derangements there are none which are more common, and none 
which more frequently produce distress, and even danger, than those 
which affect the digestive system. Under the heading of " The Signs 
of Pregnancy," the frequent occurrence of nausea and vomiting has 
already been discussed, and its most probable causes considered (p. 149). 
A certain amount of nausea is, indeed, so common an accompaniment of 
pregnancy that its consideration as one of the normal symptoms of that 
state is fully justified. We need here only discuss those cases in which 
the nausea is excessive and long-continued, and leads to serious results 
from inanition and from the constant distress it occasions. Fortunately 
a pregnant woman may bear a surprising amount of nausea and sickness 
without constitutional injury, so that apparently almost all aliments 
may be rejected without the nutrition of the body very materially suf- 
fering. At times the vomiting is limited to the early part of the day, 
when all food is rejected, and when there is a frequent retching of glairy 
transparent fluid, in several cases mixed with bile, while at the latter 
part of the day the stomach may be able to retain a sufficient quantity 
of food, and the nausea disappears. In other cases the nausea and 
vomiting are almost incessant. The patient feels constantly sick, and 
the mere taste or sight of food may bring on excessive and painful 
vomiting. The duration of this distressing accompaniment of preg- 
nancy is also variable. Generally it commences between the second 
and third months, and disappears after the woman has quickened. 
Sometimes, however, it begins with conception, and continues unabated 
until the pregnancy is over. 

Symptoms of the Graver Cases. — In the worst class of cases, 
when all nourishment is rejected, and when the retching is continuous 
and painful, symptoms of very great gravity, which may even prove 
fatal, develop themselves. The countenance becomes haggard from 
suffering, the tongue dry and coated, the epigastrium tender on press- 
ure, and a state of extreme nervous irritability, attended with restless- 
ness and loss of sleep, becomes established. In a still more aggravated 
degree, there is general feverishness, with a rapid, small, and thready 



DISEASES OF PREGNANCY. 205 

pulse. Extreme emaciation supervenes, the result of wasting from 
lack of nourishment. The breath is intensely fetid, and the tongue 
dry and black. The vomited matters are sometimes mixed with blood. 
The patient becomes profoundly exhausted, a Low form of delirium 
ensues, and death may follow if relief is not obtained. 

Prognosis. — Symptoms of such gravity are fortunately of extreme 
rarity, but they do from time to time arise, and cause much anxiety. 
Gueniot collected 118 cases of this form of the disease, out of which 
41) died; and out of the 72 that recovered, in 42 the symptoms only 
ceased when abortion, either spontaneous or artificially produced, had 
occurred. When pregnancy is over, the symptoms occasionally cease 
with marvellous rapidity. The power of retaining and assimilating 
food is rapidly regained, and all the threatening symptoms dis- 
appear. 

Treatment. — In the milder forms of obstinate vomiting, one of the 
first indications will be to remedy any morbid state of the prima? viae. 
The bowels will not unfrequently be found to be obstinately consti- 
pated, the tongue loaded, and the breath offensive; and when attention 
has been paid to the general state of the digestive organs by aperient 
medicines and antacid remedies, such as bismuth and soda and liquor 
pepticus after meals, the tendency to vomiting may abate without 
further treatment. 

The careful regulation of the diet is very important. Great benefit 
is often derived from recommending the patient not to rise from the 
recumbent position in the morning until she has taken something. 
Half a cup of milk and lime-water, or a cup of strong coffee, or a 
little rum and milk, or cocoa and milk, a glass of sparkling koumiss, 
or even a morsel of biscuit, taken on waking, often has a remarkable 
effect in diminishing the nausea. AVhen any attempt at swallowing 
solid food brings on vomiting, it is better to give up all pretence at 
keeping to regular meals, and to order such light and easily assimilated 
food, at short intervals, as can be retained. Iced milk, with lime- or 
soda-Avater, given frequently, and not more than a mouthful at a time, 
will frequently be retained when nothing else will. Cold beef-jelly, a 
spoonful at a time, will also be often kept down. Sparkling koumiss 
has been strongly recommended as very useful in such cases, and is 
worthy of trial. It is well, however, to bear in mind, in regulating 
the diet, that the stomach is fanciful and capricious, and that the 
patient may be able to retain strange and apparently unlikely articles 
of food ; and that, if she express a desire for such, the experiment of 
letting her have them should certainly be tried. 

The medicines that have been recommended are innumerable, and 
the practitioner will often have to try one after the other unsuccess- 
fully; or may find, in an individual case, that a remedy will prove 
valuable which, in another, may be altogether powerless. Amongst 
those most generally useful are effervescing draughts, containing from 
three to five minims of dilute hydrocyanic acid ; the creasote mixture 
of the Pharmacopoeia ; tincture of nux vomica, in doses of five or ten 
minims; single minim doses of vinum ipecacuanha?, every hour in severe 
cases, three or four times daily in those which are less urgent ; salicine, 



206 PREGNANCY. 

in doses of three to five grains three times a day, recommended by 
Tyler Smith ; oxalate of cerium, in the form of a pill, of which three 
to five grains may be given three times a day — a remedy strongly 
advocated by Sir James Simpson, and which occasionally is of un- 
doubted service, but more often fails ; the compound pyroxylic spirit 
of the London Pharmacopoeia, in doses of five minims every four 
hours, with a little compound tincture of cardamom, a drug which is 
comparatively little known, but which occasionally has a very marked 
and beneficial effect in checking vomiting; opiates in various forms — 
which sometimes prove useful, more often not — may be administered 
either by the mouth, in pills containing from half a grain to a grain 
of opium, or in small doses of the solution of the bi-meconate of 
morphia or of Battley's sedative solution, or subcutaneously, a mode 
of administration which is much more often successful. The hydro- 
chlorate of cocaine is said to be very efficacious ; two grains are dis- 
solved in five ounces of water, by means of spirit, of which mixture 
a teaspoonful may be taken every hour. Menthol has been highly 
recommended by Gottshalk, 1 in doses of about two grains every hour. 
Antipyrine in ten-grain doses has sometimes proved useful. If there 
is much tenderness about the epigastrium, one or two leeches may be 
advantageously applied, or one-third of a grain of morphia may be 
sprinkled on the surface of a small blister, or cloths saturated in 
laudanum may be kept over the pit of the stomach. The administra- 
tion per rectum of twenty grains of chloral, combined with the same 
amount of bromide of potassium, in a small enema, is said to be very 
useful. In many cases I have found that the application of a spinal 
ice-bag to the cervical vertebrae, in the manner recommended by Dr. 
Chapman, has checked the vomiting when all drugs have failed. The 
ice may be placed in one of Chapman's spinal ice-bags, and applied 
for half an hour or an hour, twice or three times a day. It invariably 
produces a comforting sensation of warmth, which is always agreeable 
to the patient. Ice may be given to suck ad libitum, and is very 
useful; while if there be much exhaustion, small quantities of iced 
champagne may also be given from time to time. The application of 
the ether spray over the epigastrium has been highly recommended. 

Inasmuch as the vomiting unquestionably has its origin in the 
uterus, it is only natural that practitioners should endeavor to check 
it by remedies calculated to relieve the irritability of that organ. Thus 
morphia in the form of pessaries per vaginam, or belladonna applied 
to the cervix, have been recommended, and — the former especially — are 
often of undoubted service. A pessary containing one-third to half a 
grain of morphia may be introduced night and morning without in- 
terfering with other methods of treatment. Dr. Henry JBennet directs 
especial attention to the cervix, which, he says, is almost always con- 
gested and inflamed, and covered with granular erosions. This con- 
dition he recommends to be treated by the application of nitrate of 
silver through the speculum. Dr. Amand Eouth has recently spoken 
highly of the good effects of painting the cervix with a strong solution 

1 Der Frauenarzt, March, 1891. 



DISEASES OF PREGNANCY. 207 

Dr. ( 'lay, of Manchester, advocates, especially when vom- 
iting continues in the latter months, the application or one or two 
leeches to the cervix Exception may fairly be taken to these methods 
of treatment as being somewhat hazardous, unless other means have 
been tried and tailed. L have little doubt, however, that in many 
casi>s a state of uterine congestion is an important factor in keeping 
up the unduly irritable condition of the uterine fibres, and an endeavor 
should always be made to lessen it by insisting on absolute rest in the 
recumbent posture. Of the importance of this precaution in obstinate 
cases there can be no question. Dr. Copeman, of Norwich, strongly 
recommended dilatation of the cervix by the finger, and stated that he 
found it very serviceable in checking nausea. It is obvious that this 
treatment must be adopted with great caution, as, roughly performed, 
it might lead to the production of abortion. Dr. Hewitt's views as 
to the dependence of sickness on flexions of the uterus have already 
been adverted to, and reasons have been given for doubting the gen- 
eral correctness of his theory. It is quite likely, however, that Avell- 
marked displacements of the uterus, either forward or backward, may 
serve to intensify the irritability of the organ. Cazeaux mentions an 
obstinate case immediately cured by replacing a retro verted uterus. A 
careful vaginal examination should, therefore, be instituted in all 
intractable cases, and if distinct displacement be detected, an endeavor 
should be made to support the uterus in its normal axis. If retro- 
verted, a Hodge's pessary may be safely employed ; if anteverted, a 
small air-ball pessary, as recommended by Hewitt, should be inserted. 
I believe, however, that such displacements are the exception, rather 
than the rule, in cases of severe sickness. 

The importance of promoting nutrition by every means in our power 
should always be borne in mind. The effervescing koumiss, which can 
now be readily obtained, I have found of great value, as it can often 
be retained when all other aliment is rejected. The exhaustion pro- 
duced by want of food soon increases the irritable state of the nervous 
svstem, and, if the stomach will not retain anything, we can only 
combat it by occasional nutrient enemata of strong beef-tea, yolk of 
egcr, and the like. 

The Production of Artificial Abortion. — Finally, in the worst 
class of cases, when all treatment has failed, and when the patient has 
fallen into the condition of extreme prostration already described, Ave 
may be driven to consider the necessity of producing abortion. For- 
tunately cases justifying this extreme resource are of great rarity, but 
nevertheless there is abundant evidence that every now and then women 
do die from uncontrollable vomiting whose lives might have been saved 
had the pregnancy been brought to an end. The value of artificial 
abortion has been abundantly proved. Indeed, it is remarkable how 
rapidly the serious symptoms disappear when the uterus is emptied, 
and the tension of the uterine fibres lessened. It has fortunately but 
rarely fallen to my lotto have to perform this operation for intractable 
In one such case the patient was reduced to a state of the 

i Brit. Med. Journ., June G, 1S91. 



208 PREGNANCY. 

utmost prostration, having kept hardly any food on her stomach for 
many weeks, and when I first saw her she was lying in a state of low 
muttering delirium. Within a few hours after abortion was induced 
all the threatening symptoms had disappeared, the vomiting had entirely 
ceased, and she was next day able to retain and absorb all that was 
given to her. The value of the operation, therefore, I believe to be 
undoubted. Where it has failed it seems to have been on account of 
undue delav. Owing to the natural repugnance which all must feel 
toward this plan, it has generally been postponed until the patient has 
been too exhausted to rally. If, therefore, it is done at all, it should 
be before prostration has advanced so far as to render the operation 
useless. In these cases the obvious indication is to lessen the tension 
of the uterus at once, and, therefore, the membranes should be punc- 
tured by the uterine sound, so as to let the liquor amnii drain away, 
and this may of itself be sufficient to accomplish the desired effect. It 
is almost needless to add, that no one would be justified in resorting to 
this expedient without having his opinion fortified by consultation with 
a fellow-practitioner. 

Other disorders of the digestive system may give rise to con- 
siderable discomfort, but not to the serious peril attending obstinate 
vomiting. Amongst them are loss of appetite, acidity and heartburn, 
flatulent distention, and sometimes a capricious appetite, which assumes 
the form of longing for strange and even disgusting articles of diet. 
Associated with these conditions there is generally derangement of the 
whole intestinal tract, indicated by furred tongue and sluggish bowels, 
and they are best treated by remedies calculated to restore a healthy 
condition of the digestive organs, such as a light, easily digested diet, 
mineral acids, vegetable bitters, occasional aperients, bismuth and soda, 
and pepsin. The indications for treatment are not different from those 
which accompany the same symptoms in the non-pregnant state. 

Diarrhoea is an occasional accompaniment of pregnancy, often 
depending on errors of diet. When excessive and continuous it has a 
decided tendency to induce uterine contractions, and I have frequently 
observed premature labor to follow a sharp attack of diarrhoea. It 
should, therefore, not be neglected ; and if at all excessive, should be 
checked by the usual means, such as chalk mixture with aromatic con- 
fection, and small doses of laudanum or chlorodyne. The possibility 
of apparent diarrhoea being associated with actual constipation, the 
fluid matter finding its way past the solid materials blocking up the 
intestines, should be borne in mind. 

Constipation is much more common, and is indeed a very general 
accompaniment of pregnancy, even in women who do not suffer from 
it at other times. It partly depends on the mechanical interference of 
the gravid uterus with the proper movements of the intestines, and 
partly on defective innervation of the bowels resulting from the altered 
state of the blood. The first indication will be to remedy this defect 
by appropriate diet, such as fresh fruits, brown bread, oatmeal por- 
ridge, etc. Some medicinal treatment will also be necessary, and, in 
selecting the drugs to be used, care should be taken to choose such as 
are mild and unirritating in their action, and tend to improve the 



DISEASES OF PREGNANCY. 2U ( J 

tone of the muscular coat of the intestine. A small quantity of aperient 
mineral water in the early morning, such as the Hunyadi, Friearichs- 
balle, or Pullna water, often answers very well ; or an occasional dose 
of the confection of sulphur ; or a pill containing three or four grains 
of the extract of colocynth, with a quarter of a grain of tin? extract of 
mix vomica ami a grain of extract of hyoscyamus, at bedtime; or a 
teaspoonful of the compound liquorice powder in milk at bedtime. 
Constipation is also sometimes effectually combated by administering, 
twice daily, a pill containing a couple of grains of the inspissated ox- 
gall, with a quarter of a grain of extract of belladonna. Enemata of 
soap and water are often very useful, and have the advantage of not 
disturbing the digestion. In the latter months of pregnancy, especially 
in the few weeks preceding delivery, the irritation produced by the 
collection of hardened feces in the bowel is a not iafrequent canse of 
the annoying false pains which then so commonly trouble the patient. 
In order to relieve them, it will be necessary to empty the bowels 
thoroughly by an aperient, such as a good dose of castor oil, to which 
fifteen or twenty minims of landanimi may be advantageously added. 
Should the rectum become loaded with scybalous masses, it may be 
necessary to break down and remove them by mechanical means, 
provided we are unable to effect this by copions enemata. 

Hemorrhoids. — The loaded state of the rectum so common in preg- 
nancy, combined with the mechanical effect of the pressure of the 
gravid uterus on the hemorrhoidal veins, often produces very trouble- 
some symptoms from piles. In such cases a regular and gentle evacu- 
ation of the bowels should be secured daily, so as to lessen as much as 
possible the congestion of the veins. Auy of the aperients already 
mentioned, especially the sulphur electuary, may be used. Dr. For- 
dyee Barker 1 insists that, contrary to the usual impression, one of the 
best remedies for this purpose is a pill containing a grain or a grain 
and a half of powdered aloes, with a quarter of a grain of extract of 
nux vomica, and that castor oil is distinctly prejudicial, and apt to 
increase the symptoms. I have certainly found it answer Avell in 
several cases. When the piles are tender and swollen, they should be 
freely covered with an ointment consisting of four grains of muriate of 
morphia to an ounce of simple ointment, or with the ung. galla? cum 
opio of the Pharmacopoeia ; and, if protruded, an attempt should be 
made to push them gently above the sphincter, by which they are 
often unduly constricted. Relief may also be obtained by frequent 
hot fomentations, and sometimes, when the piles are much swollen, it 
will be found useful to puncture them, so as to lessen the congestion, 
before any attempt at reduction is made. 

Ptyalism. — A profuse discharge from the salivary glands is an occa- 
sional distressing accompaniment of pregnancy. It is generally con- 
fined to the early months, but it occasionally continues during the 
whole period of gestation, and resists all treatment, only ceasing when 
delivery is over. Under such circumstances the discharge of saliva is 
sometimes enormous, amounting to several quarts a day, and the dis- 

1 The Puerperal Diseases, p. 33. 
14 



210 PREGNANCY. 

tress and annoyance to the patient are very great. In one case under 
my care the saliva poured from the mouth all day long, and for several 
months the patient sat with a basin constantly by her side, incessantly 
emptying her mouth, until she was reduced to a condition giving rise 
to really serious anxiety. This profuse salivation is, no doubt, a purely 
nervous disorder, and not readily controlled by remedies. Astringent 
gargles, containing tannin and chlorate of potash, frequent sucking of 
ice or of tannin lozenges, inhalation of turpentine and creasote, counter- 
irritation over the salivary glands by blisters or iodine, the continuous 
galvanic current applied over the parotids, the bromides, opium inter- 
nally, small doses of belladonna or atropine, may all be tried in turn, 
but none of them can be depended on with any degree of confidence. 

Toothache and Caries of the Teeth. — Severe dental neuralgia is 
also a frequent accompaniment of pregnancy, especially in the early 
months. When purely neuralgic, quinine in tolerably large doses is 
the best remedy at our disposal ; but not unfrequently it depends on 
actual caries of the teeth, and attention should always be paid to the 
condition of the teeth when facial neuralgia exists. There is no doubt 
that pregnancy predisposes to caries, and the observation of this fact 
has given rise to the old proverb, " For every child a tooth." Mr. 
Oakley Coles, in an interesting paper 1 on the condition of the mouth 
and teeth during pregnancy, refers the prevalence of caries to the co- 
existence of acid dyspepsia, causing acidity of the oral secretions. 
There is much unreasonable dread amongst practitioners as to inter- 
fering with the teeth during pregnancy, and some recommend that all 
operations, even filling, should be postponed until after delivery. 
It seems to me certain that the suffering of severe toothache is likely 
to give rise to far more severe irritation than the operation required 
for its relief, and I have frequently seen badly decayed teeth extracted 
during pregnancy, and with only a beneficial result. 

Affections of the Respiratory Organs. — Amongst the derange- 
ments of the respiratory organs, one of the most common is spasmodic 
cough, which is often excessively troublesome. Like many other of 
the sympathetic derangements accompanying gestation, it is purely 
nervous in character, and is unaccompanied by elevated temperature, 
quickened pulse, or any distinct auscultatory phenomena. In character 
it is not unlike whooping-cough. The treatment must obviously be 
guided by the character of the cough. Expectorants are not likely to 
be of service, while benefit may be derived from some of the anti- 
spasmodic class of drugs, such as belladonna, hydrocyanic acid, opiates, 
or bromide of potassium. Such remedies may be tried in succession, 
but will often be found to be of little value in arresting the cough. 
Dyspnoea may also be nervous in character, and sometimes symptoms 
not unlike those of spasmodic asthma are produced. Like the other 
sympathetic disorders, it, as well as nervous cough, is most frequently 
observed during the early months. There is another form of dyspnoea, 
not uncommonly met with, which is the mechanical result of the inter- 
ference with the action of the diaphragm and lungs by the pressure of 

1 Trans, of the Odontological Society. 



DISEASES OF PREGNANCY. 211 

the enlarged uterus. Hence this Is most generally troublesome in the 

latter months, and continues unrelieved until delivery, or until the 
sinking of the uterine tumor which immediately precedes it. Beyond 
taking care that the pressure is not Increased by tight lacing or injudi- 
cious arrangement 01 the clothes, there is little that can he done to 
relieve this form of breathlessness. 

Palpitation. — Palpitation, like dyspnoea, may he due either to sym- 
pathetic disturbance, or to mechanical interference with the proper 
action of the heart. When occurring in weakly women it may he 
referred to the functional derangements which accompany the chlorotic 
condition of the blood aften associated with pregnancy, and is then 
best remedied by a general tonic regimen, and the administration of 
ferruginous preparations. At other times anti-spasmodic remedies may 
be indicated, and it is seldom sufficiently serious to call for much 
special treatment. 

Syncope. — Attacks of fainting are not rare, especially in delicate 
women of highly developed nervous temperament, and are, perhaps, 
most common at or about the period of quickening. In most cases 
these attacks cannot be classed as cardiac, but are more probably 
nervous in character, and they are rarely associated with complete 
abolition of consciousness. They rather, therefore, resemble the condi- 
tion described by the older authors as Leipothymia. The patient lies 
in a semi-uuconseious condition with a feeble pulse and widely dilated 
pupils, and this state lasts for varying periods, from a few minutes to 
half an hour or more. In one very troublesome case under my care 
they often recurred as frequently as three or four times a day. I have 
observed that they rarely occur when the more common sympathetic 
phenomena of pregnancy, especially vomiting, are present. Sometimes 
they terminate with the ordinary symptoms of hysteria, such as sob- 
biug. The treatment should consist during the attack in the adminis- 
tration of diffusible stimulants, such as ether, salvolatile, and valerian, 
the patient being placed in the recumbent position, with the head low. 
If frequently repeated it is unadvisable to attempt to rally the patient 
by the too free administration of stimulants. In the intervals a gener- 
ally tonic regimen, and the administration of ferruginous remedies, 
are indicated. If they recur with great frequency, the daily applica- 
tion of the spinal ice-bag has proved of much service. 

Extreme Anaemia and Chlorosis. — In connection with disorders 
of the circulatory system may be noticed those which depend on the 
state of the blood. The altered condition of the blood, which has 
already been described as a physiological accompaniment of pregnancy 
(p. 145), is sometimes carried to an extent which may fairly be called 
morbid ; and either on account of the deficiency of blood corpuscles, 
or from the increase in its watery constituents, a state of extreme 
anaemia and chlorosis may be developed. This may be sometimes 
carried to a very serious extent, the condition amounting to that 
known as "pernicious anaemia." Thus Gusserow 1 records five cases, 
in which nothing but excessive anaemia could be detected, all of which 

i Arch. f. Gyn., 1871, Bd. ii. S. 218. 



212 PREGNANCY. 

ended fatally. Generally when sueh symptoms have been carried to 
an extreme extent, the patient has been in a state of chlorosis before 
pregnancy. In cases of this aggravated type the patient will prob- 
ably miscarry, and the induction of premature labor or abortion may 
even become imperative. 

Treatment. — The treatment must, of course, be calculated to im- 
prove the general nutrition, and enrich the impoverished blood ; a light 
and easily assimilated diet, milk, eggs, beef-tea, and animal food — if 
it can be taken ; attention to the proper action of the bowels, a due 
amount of stimulants, and abundance of fresh air, will be the chief 
indications in the general management of the case. Medicinally, 
ferruginous preparations will be required. Some practitioners object, 
apparently without sufficient reason, to the administration of iron 
during pregnancy, as liable to promote abortion. This unfounded 
prejudice may probably be traced to the supposed emmenagogue prop- 
erties of the preparations of iron; but, if the general condition of 
the patient indicate such medication, they may be administered without 
any fear. Preparations of phosphorus, such as the phosphide of zinc, 
or free phosphorus, also promise favorably, and are well worthy of 
trial. 

Some of the more aggravated cases are associated with a consider- 
able amount of serous effusion into the cellular tissue, generally limited 
to the lower extremities, but occasionally extending to the arms, face, 
and neck, and even producing ascites and pleuritic effusion. Under 
the latter circumstances this complication is, of course, of great gravity, 
and it is said that after delivery the disappearance of the serous effusion 
may be accompanied by metastasis of a fatal character to the lungs or 
the nervous centres. This form of oedema must be distinguished from 
the slight (edematous swelling of the feet and legs so commonly ob- 
served as a mechanical result of the pressure of the gravid uterus, and 
also from those cases of oedema associated with albuminuria. The 
treatment must be directed to the cause, while the disappearance of the 
effusion may be promoted by the administration of diuretic drinks, the 
occasional use of saline aperients, and rest in the horizontal position. 

Albuminuria. — The existence of albumin in the urine of pregnant 
women has for many years attracted the attention of obstetricians, and 
it is now well known to be associated, in ways still imperfectly under- 
stood, with many important puerperal diseases. Its presence in most 
cases of puerperal eclampsia was long ago pointed out by Lever in 
this country and Raver in France, and its association with this disease 
gave rise to the theory of the dependence of the convulsion on uraemia, 
which is generally still entertained. It has been shown of late years, 
especially by Braxton Hicks, that this association is by no means so 
universal as was supposed ; or rather, that in some cases the albumin- 
uria follows and does not precede the convulsions, of which it might 
therefore be supposed to be the consequence rather than the cause ; so 
that further investigations as to these particular points are still required. 
Modern researches have shown that there is an intimate connection 
between many other affections and albuminuria; as, for example, 
certain forms of paralysis, either of special nerves, as puerperal 



DISEASES OF PREGNANCY. 213 

amaurosis, or of the spinal system; cephalalgia and dizziness; puer- 
peral mania; and possibly hemorrhage. It cannot, therefore, be 
doubted thai albuminuria in the pregnant woman is liable, at any rate, 
to be associated with grave disease, although the present state of our 
knowledge docs not enable us to define very distinctly its precise mode 
of action. 

The presence of albumin in the urine of pregnant women is far 
from a rare phenomenon. Blot and Litzman met with albuminuria 
in 20 per cent, of pregnant women, which is, however, far above the 
estimate of other authors; Fordyce Barker 1 thinks it occurs in about 
one out of 25 cases, or 4 per cent.; Hofmeier 2 found it in 137 out 
of 5000 deliveries in the Berlin Gynecological Institution, or 2.74 
per cent. ; while, more recently, Leopold Meyer 3 found it in 5.4 per 
cent, out of 1124 cases, with casts in 2 per cent. As in most of these 
cases it rapidly disappears alter delivery, it is obvious that its presence 
must, in a large proportion of eases, depend on temporary causes, and 
has not always the same serious importance as in the non-pregnant 
state. This is further proved by the undoubted fact that albumin, 
rapidly disappearing after delivery, is often found in the urine of 
pregnant women who go to term, and pass through labor without any 
unfavorabl e symptoms. 

Pressure by the Gravid Uterus. — The obvious facts that in 
pregnancy the vessels supplying the kidneys are subjected to mechan- 
ical pressure from the gravid uterus, and that congestion of the venous 
circulation of those viscera must necessarily exist to a greater or less 
degree, suggest that here we may find an explanation of the frequent 
occurrence of albuminuria. This view is further strengthened by the 
fact that the albumin rarely appears until after the fifth month, and, 
therefore, not until the uterus has attained a considerable size ; and 
also that it is comparatively more frequently met with in primipara?, 
in whom the resistance of the abdomiual parietes, and consequent 
pressure, must be greater than in women who have already borne 
children. It is, indeed, probable that pressure and consequent venous 
congestion of the kidneys have an important influence in its produc- 
tion ; but there must be, as a rule, some other factors in operation, 
since an equal or even greater amount of pressure is often exerted by 
ovarian and fibroid tumors, without any such consequences. They are 
probably complex. One important condition is doubtless the increased 
amount of work the kidneys have to do in excreting the waste prod- 
ucts of the foetus, as well as those of the mother. The increased 
arterial tension throughout the body associated with hypertrophy of 
the heart, known to exist in pregnancy, also operates in the same 
direction. But in the large majority of cases, although these condi- 
tions are present, no albuminuria exists, and they must, therefore, be 
looked upon as predisposing causes, to which some other is added 
before the albumin escapes from the vessels. What this is generally 
escapes our observation, but probably any condition producing sudden 

1 American Journal of Obstetrics, 187S, vol. xi. p. 449. 

2 Berlin, klin. Wochenschr., September. 1878. 

3 Zeitschr. fur Geb. u. Gyn., Band xvi. S. 215. 



214 PREGNANCY. 

hyperemia of the kidneys, and giying rise to a state analogous to the 
first stage of Bright's disease — such, for example, as sudden exposure 
to cold and impeded cutaneous action — may be sufficient to set a light 
to the match already prepared by the existence of pregnancy. It has 
more recently been pointed out that a transient albuminuria, disap- 
pearing in a few days, is very common during and after labor, and 
probably depends on a catarrhal condition of the urinary tract. 
Ingersten 1 observed this in 50 out of 153 deliveries, and in 15 only 
had any albumin existed before the confinement; and Meyer 2 in 25 
per cent, out of 11,138 women in labor, with casts in 12 per cent. 
In addition to these temporary causes it must not be forgotten that 
pregnancy may supervene in a patient already suffering from Bright's 
disease, when, of course, the albumin will exist in the urine from the 
commencement of gestation. 

The various diseases associated with the presence of albumin in the 
urine will require separate consideration. Some of these, especially 
puerperal eclampsia, are amongst the most dangerous complications of 
pregnancy. Others, such as paralysis, cephalalgia, dizziness, may also 
be of considerable gravity. The precise mode of their production, 
aud whether they can be traced, as is generally believed, to the reten- 
tion of urinary elements in the blood, either urea or free carbonate of 
ammonia produced by its decomposition, or whether the two are only 
common results of some undetermined cause, will be considered when 
Aye come to discuss puerperal convulsions. Whatever view may ulti- 
mately be taken on these points, it is sufficiently obvious that albu- 
minuria in a pregnant woman must constantly be a source of much 
anxiety, and must induce us to look forward with considerable appre- 
hension to the termination of the case. 

Prognosis. — We are scarcely in possession of a sufficiently large 
number of observations to justify any very accurate conclusions as to 
the risk attending albuminuria during pregnancy, but it is certainly 
by no means slight. Hofmeier believes that albuminuria is a most 
severe complication both for woman and child, even when uncompli- 
cated with eclampsia. The prognosis, he thinks, depends on whether 
it is acute in its onset, that is, coming on within a few days of labor, 
or is extended over several weeks. The former is more likely to pass 
entirely away after delivery, while in the latter there is more risk of 
the morbid state of the kidneys becoming permanent, and leading to 
the establishment of Bright's disease after the pregnancy is over. 
Goubeyre estimated that 49 per cent, of primiparae who have albu- 
minuria, and who escape eclampsia, die from morbid conditions trace- 
able to the albuminuria. This conclusion is probably much exagger- 
ated, but, if it even approximate to the truth, the danger must be very 
great. 

Besides the ultimate risk to the mother, albuminuria strongly pre- 
disposes to abortion, no doubt on account of the imperfect nutrition of 
the foetus by blood impoverished by the drain of albuminous materials 
through the kidneys. This fact has been observed by many writers. 

1 Zeitschrift f. Geburt. u. Gyniik., 1879, Band v. Heft 2. 2 op. cit. 



DISK ASKS OF PB KG NANCY. 215 

A good illustration of it is given by Tanner, 1 who states that four oui 
of seven women be attended suffering from Bright's disease during 
pregnancy, aborted, one of them three times in succession. 

Symptoms. — The symptoms accompanying albuminuria in preg- 
nancy are by no means uniform or constantly present. Thai which 
most frequently causes suspicion is anasarca — not only the (Edematous 
swelling of the lower limbs which is so common a consequence of the 
pressure of the gravid uterus, but also of the lace and upper extremi- 
ties. Any puffiness or in lilt ration about the face, or any oedema about 
the hands or arms, should always give rise to suspicion, and lead to a 
careful examination of the urine. Sometimes this is carried to an 
exaggerated degree, so that there is anasarca of the whole body. 

Anomalous nervous symptoms — such as headache, transient dizzi- 
uess, dimness of vision, spots before the eyes, inability to see objects 
distinctly, sickness in women not at other times suffering from nausea, 
sleeplessness, irritability of temper — are also often met with, some- 
times to a slight degree, at others very strongly developed, and should 
always arouse suspicion. Indeed, knowing as we do that many morbid 
states may be associated Avith albuminuria, we should make a point of 
carefully examining the urine of all patients in whom any unusually 
morbid phenomena show themselves during pregnancy. 

The condition of the urine varies considerably, but it is generally 
scanty and highly colored, and, in addition to the albumin, especially 
in cases in which the albuminuria has existed for some time, we may 
find epithelium cells, tube-casts, and occasionally blood corpuscles. 

Treatment. — The treatment must be based on what has been said 
as to the causes of the albuminuria. Of course, it is out of our power 
to remove the pressure of the gravid uterus, except by inducing labor ; 
but its effects may at least be lessened by remedies tending to promote 
an increased secretion of urine, and thus diminishing the congestion 
of the renal vessels. The administration of saline diuretics, such as 
the acetate of potash, or bitartrate of potash, the latter being given 
in the form of the well-known imperial drink, will best answer this 
indication. The action of the bowels may be excited by purgatives 
producing watery motions, such as occasional doses of compound jalap 
powder. Dry cupping over the loins, frequently repeated, has a bene- 
ficial effect in lessening the renal hyperemia. The action of the skin 
should also be promoted by the use of the vapor bath, and with this 
view the Turkish bath may be employed with great benefit and perfect 
safety. Jaborandi and pilocarpin have been given for this purpose, 
but have been found by Fordyce Barker to produce a dangerous degree 
of depression. The next indication is to improve the condition of the 
blood by appropriate diet and medication. A very light and easily 
assimilated diet should be ordered, of which milk should form the 
staple. Tarnicr 2 has recorded several cases in which a purely milk 
diet was very successful in removing albuminuria. With the milk, 
which should be skimmed, we may allow white of egg, or a little white 
fish. The tincture of the perchloride of iron is the best medicine we 

1 Signs and Diseases of Pregnancy, p. 428. 

2 Annal. de Gynec., 1876, torn. v. p. 41. 



216 PREGNANCY. 

can give, and it may be advantageously combined with small doses of 
tincture of digitalis, which acts as an excellent diuretic. 

Finally, in obstinate cases we shall have to consider the advisability 
of inducing premature labor. The propriety of this procedure in the 
albuminuria of pregnancy has of late years been much discussed. 
Spiegelberg 1 is opposed to it, while Barker 2 thinks it should only be 
resorted to " when treatment has been thoroughly and perseveringly 
tried without success for the removal of symptoms of so grave a char- 
acter that their continuance would result in the death of the patient." 
Hofineier, 3 on the other hand, is in favor of the operation, which he 
does not think increases the risk of eclampsia, and may avert it 
altogether. I believe that, having in view the undoubted risks which 
attend this complication, the operation is unquestionably indicated, 
and is perfectly justifiable, in all cases attended with symptoms of 
serious gravity. It is not easy to lay down any definite rules to guide 
our decision ; but I should not hesitate to adopt this resource in all 
cases in which the quantity of albumin is considerable and progressively 
increasing, and in which treatment has failed to lessen the amount ; 
and, above all, in every case attended with threatening symptoms, 
such as severe headache, dizziness, or loss of sight. The risks of the 
operation are infinitesimal compared with those which the patient 
would run in the event of puerperal convulsions supervening, or 
chronic Bright's disease becoming established. As the operation is 
seldom likely to be indicated until the child has reached a viable age, 
and as the albuminuria places the child's life in danger, we are quite 
justified in considering the mother's safety alone in determining on its 
performance. 

Diabetes. — The occurrence of pregnancy in a woman suffering from 
diabetes may lead to serious consequences, and has recently been 
specially investigated by Dr. Matthews Duncan. 4 This must be 
carefully distinguished from the physiological glycosuria commonly 
present at the end of pregnancy, and during lactation. It is probable 
that diabetic patients are inapt to conceive, but when pregnancy does 
occur under such conditions, the case cannot be considered devoid of 
anxiety. From the cases collected by Dr. Duncan it would appear 
that pregnancy is very liable to be interrupted in its course, generally 
by the death of the foetus, which has very often occurred. In some 
instances no bad results have been observed, while in others the 
patient has collapsed after delivery. Diabetic coma does not seem to 
have been observed. Out of twenty-two pregnancies in diabetic 
women four ended fatally, so that the mortality is obviously very 
large. Too little is known on this subject to justify positive rules of 
treatment ; but if the symptoms are serious and increasing, it would 
probably be justifiable to induce labor prematurely, so as to lessen the 
strain to which the patient's constitution is subjected. 

1 Lehrbuch der Geburt. 

2 Arner. Journ. of Obstet, 1878, vol. xi. p. 449. 
s Op. cit. 

* Obst. Trans., 18S2, vol. xxiv. p. 256. 



DISEASES OF PKEGNANOY. 217 



CHAPTER VIII. 

DISEASES OF PREGNANCY— Continued. 

Disorders of the Nervous System. — There are many disorders of 
the nervous system met with during the course of pregnancy. Among 
the most common are morbid irritability of temper, or a state of mental 
despondency and dread of the results of the labor, sometimes almost 
amounting to insanity, or even progressing to actual mania. These 
are but exaggerations of the highly susceptible state of the nervous 
system generally associated with gestation. Want of sleep is not 
uncommon, and, if carried to any great extent, may cause serious 
trouble from the irritability and exhaustion it produces. In such 
cases we should endeavor to lessen the excitable state of the nerves, 
by insisting on the avoidance of late hours, overmuch society, exciting 
amusements, and the like ; while it may be essential to promote sleep 
by the administration of sedatives, none answering so well as the 
chloral hydrate, in combination with large doses of bromide of potas- 
sium or sodium, which greatly intensify its hypnotic effects. 

Severe headaches and various intense neuralgia? are common. 
Amongst the latter the most frequently met with are pain in the 
breasts, due to the intimate sympathetic connection of the mamma? 
with the gravid uterus; and intense intercostal neuralgia, which a 
careless observer might mistake for pleuritic or inflammatory pain. 
The thermometer, by .showing that there is no elevation of tempera- 
ture, would prevent such a mistake. Neuralgia of the uterus itself, 
or severe pains in the groins or thighs — the latter being probably the 
mechanical results of dragging on the attachments of the abdominal 
muscles — are also far from uncommon. In the treatment of such 
neuralgic aifections attention to the state of the general health, and 
large doses of quinine and ferruginous preparations whenever there is 
much debility, will be indicated. Locally sedative applications, such 
as belladonna and chloroform liniments ; friction with aconite oint- 
ment when the pain is limited to a small space ; and, in the worst 
cases, the subcutaneous injection of morphia, will be called for. Those 
pains which apparently depend on mechanical causes may often be 
best relieved by lessening the traction on the muscles, by wearing a 
well-made elastic belt to support the uterus. 

Paralysis. — Among the most interesting of the nervous diseases are 
various paralytic aifections. Almost all varieties of paralysis have 
been observed, such as paraplegia, hemiplegia (complete or incomplete), 
facial paralysis, and paralysis of the nerves of special sense, giving 
rise to amaurosis, deafness, and loss of taste. Churchill records 
twenty-two cases of paralysis during pregnancy, collected by him from 



218 PREGNANCY. 

various sources. A large number have also been brought together by 
Imbert Goubeyre, in an interesting memoir on the subject, and others 
are recorded by Fordyce Barker, Joulin, and other authors; so that 
there can be no doubt of the fact that paralytic affections are common 
during gestation. In a large proportion of the cases recorded the 
paralyses have been associated with albuminuria, and are doubtless 
uraemic in origin. Thus in nineteen cases, related by Goubeyre, albu- 
minuria was present in all ; Darcy, 1 however, found no albuminuria in 
five out of fourteen cases. The dependency of the paralysis on a transient 
cause explains the fact that in a large majority of these cases it was 
not permanent, but disappeared shortly after labor. In every case of 
paralysis, whatever be its nature, special attention should be directed 
to the state of the urine, and, should it be found to be albuminous, 
labor should be at once induced. This is clearly the proper course to 
pursue, and we should certainly not be justified in running the risk 
that must attend the progress of a case in which so formidable a 
symptom has already developed itself. When the cause has been 
removed, the effect will also generally rapidly disappear, aud the 
prognosis is therefore, on the whole, favorable. Should the paralysis 
continue after delivery, the treatment must be such as we would adopt 
in the non-pregnant state ; and small doses of strychnia, along with 
faradization of the affected limbs, would be the best remedies at oar 
disposal. 

There are, however, unquestionably some cases of puerperal paralysis 
which are not uraemic in their origin, and the nature of which is some- 
what obscure. Hemiplegia may doubtless be occasioned by cerebral 
hemorrhage, as in the non-pregnant state. Other organic causes of 
paralysis, such as cerebral congestion, or embolism, may, now and 
again, be met with during pregnancy, but cases of this kind must be 
of comparative rarity. Other cases are functional in their origin. 
Tarnier relates a case of hemiplegia which he could only refer to 
extreme anaemia. Some, again, may be hysterical. Paraplegia is 
apparently more frequently unconnected with albuminuria than the 
other forms of paralysis ; and it may either depend on pressure of the 
gravid uterus on the nerves as they pass through the pelvis, or on 
reflex action, as is sometimes observed in connection with uterine 
disease. When, in such cases, the absence of albuminuria is ascer- 
tained by frequent examination of the urine, there is obviously not the 
same risk to the patient as in cases depending on uraemia, and, there- 
fore, it may be justifiable to allow pregnancy to go on to term, trusting 
to subsequent general treatment to remove the paralytic symptoms. 
As the loss of power here depends on a transient cause, a favorable 
prognosis is quite justifiable. Partial paralysis of one lower extremitv, 
generally the left, sometimes occurs, from pressure of the foetal occiput, 
and may continue for days, or weeks, with a gradual improvement, 
after parturition. 

Chorea. — Chorea is not infrequently observed, and forms a serious 
complication. It is generally met with in young women of delicate 

i These de Paris, 1877- 



D I S E A S E S O F PREGNANCY. 219 

health, and in the first pregnancy. In a large proportion of the cases 
the patient has already suffered from the disease before marriage. ( )n 
the occurrence of pregnancy, the disposition of the disease again be- 
comes evoked, and choreic movements are re-established. This fad 
may be explained partly by the susceptible state of the nervous system, 
partly by the impoverished condition of the blood. 

Prognosis. — That chorea is a dangerous complication of pregnancy 
is apparent by the fact that out 01 fifty-six cases collected by Dr. 
Barnes 1 do less than seventeen, or one in three, proved fatal. Nor Is 
it danger to life alone that is to be feared, for it appears certain that 
chorea is more apt to leave permament mental disturbance when it 
occurs during pregnancy than at other times. It lias also an unques- 
tionable tendency to bring on abortion or premature labor, and in most 
cases the life of the child is sacrificed. 

Treatment. — The treatment of chorea during pregnancy does not 
differ from that of the disease under more ordinary circumstances ; and 
our chief reliance will be placed on such drugs as the liquor arsenicalis, 
bromide of potassium, and iron. In the severe form of the disease, 
the incessant movements, and the weariness and loss of sleep, may very 
seriously imperil the life of the patient, and more prompt and radical 
measures will be indicated. If, in spite of our remedies, the paroxysms 
go on increasing in severity, and the patient's strength appears to be 
exhausted, our only resource is to remove the most evident cause by 
inducing labor. Generally the symptoms lessen and disappear soon 
after this is done. There can be no question that the operation is per- 
fectly justifiable, and may even be essential under such circumstances. 
It should be borne in mind that the chorea often recurs in a subsequent 
pregnancy, and extra care should then always be taken to prevent its 
development. 

Tetanus. — Tetanus has not infrequently been observed in connection 
with pregnancy in the tropics, where the disease is common. In tem- 
perate climates it is exceedingly rare, and has been more often met 
with after abortion than after labor at term. Little is known of this 
complication of pregnancy, either as to its cause, or of the modifi- 
cation of the symptoms which may show themselves. The risk to the 
patient, however, is very great. Out of thirty cases recorded — twenty- 
eight by Simpson and two by Wiltshire — only six recovered. 

Disorders of the Urinary Organs. Retention of Urine. — Dis- 
orders of the urinary organs are of frequent occurrence. Retention of 
urine may be met with, and this is often the result of a retroverted 
nterns. The treatment, therefore, must then be directed to the removal 
of the cause. This subject will be more particularly considered when 
we come to discuss that form of displacement (p. 223); but we may 
here point out that retention of urine, if long continued, may not only 
lead to much distress, but to actual disease of the coats of the bladder. 
Several eases have been recorded in which cystitis, resulting from 
urinary retention in pregnancy, eventually caused the exfoliation of 
the entire mucous membrane of the bladder, 2 which was cast off, some- 

» Obst. Trans.. 1889, vol. x. p. 147. 2 Ibid.. 1S63, vol. iv. p. 13. 



220 PREGNANCY. 

times entire, sometime in shreds, and occasionally with portions of the 
muscular coat attached to it. The possibility of this formidable accident 
should teach us to be careful not to allow any undue retention of urine, 
but, by a timely use of the catheter, to relieve the symptoms, while 
we, at the same time, endeavor to remove the cause. 

Irritability of the bladder is of frequent occurrence. In the early 
months it seems to be the consequence of sympathetic irritation of the 
neck of the bladder, combined with pressure, while in the later months 
it is, probably, solely produced by mechanical causes. When severe 
it leads to much distress, the patient's rest being broken and disturbed 
by incessant calls to micturate, and the suffering induced may produce 
serious constitutional disturbances. I have elsewhere pointed out 1 that 
irritability of the bladder in the later months of pregnancy is frequently 
associated with an abnormal position of the foetus, which is placed 
transversely or obliquely. The result is either that undue pressure is 
applied to the bladder, or that it is drawn out of its proper position. 
The abnormal position of the foetus can be easily detected by palpation, 
and is readily altered by external manipulation. In some of the cases 
I have recorded, altering the position of the foetus was immediately 
followed by relief; the symptoms recurring after a time, when the 
foetus had again assumed an oblique position. Should the foetus fre- 
quently become displaced, an endeavor may be made to retain it in the 
longitudinal axis of the uterus by a proper adaptation of bandages and 
pads. In cases not referable to this cause we should attempt to relieve 
the bladder symptoms by appropriate medication, such as small doses 
of liquor potassse, if the urine be very acid ; tincture of belladonna ; 
the decoction of triticum repens, an old but very serviceable remedy ; 
and vaginal sedative pessaries containing morphia or atropine. 

Women who have borne many children are often troubled with 
incontinence of urine during pregnancy, the water dribbling away on 
the slightest movement. Through this much irritation of the skin 
surrounding the genitals is produced, attended with troublesome exco- 
riations and eruptions. Relief may be partially obtained by lessening 
the pressure on the bladder by an abdominal belt, while the skin is 
protected by applications of simple ointment or vaseline. 

Dr. Tyler Smith has directed attention to a phosphatic condition of 
the urine occurring in delicate women, whose constitutions are severely 
tried by gestation. This condition can easily be altered by rest, nutri- 
tious diet, and a course of restorative medicine, such as steel, mineral 
acids, and the like. 

Leucorrhcea. — A profuse, whitish, leucorrhoeal discharge is very 
common during pregnancy, especially in its latter half. The discharge 
frequently alarms the patient, but, unless it is attended with disagree- 
able symptoms, it does not call for special treatment. When at all 
excessive, it may lead to much irritation of the vagina and external 
generative organs. The labia may become excoriated and covered with 
small aphthous patches, and the whole vulva may be hot, swollen, and 
tender. Warty growths, similar in appearance to syphilitic condylo- 

1 Ibid., 1872, vol. xiii. p. 42. 



DISEASES OF PREGNANCY. 221 

mata, are occasionally developed in pregnant women, unconnected with 
any specific taint, and associated with the presence of an irritating 
leucorrhoeal discharge. According to Thibierge, 1 these resist local 
applications, such as sulphate of copper or nitrate of silver, but spon- 
taneously disappear alter delivery, [nasmuch as the leucorrhoeal 
discharge is dependent on the congested condition of the generative 
organs accompanying pregnancy, we can hope to do little more than 
alleviate it. In the severer forms, as has been pointed out by Henry 
1 Jennet, the cervix will be found to be abraded or covered with granular 
erosion, and it may be, from time to time, cautiously touched with the 
nitrate of silver or a solution of carbolic acid. Generally speaking, 
we must content ourselves with recommending the patient to wash the 
vagina out gently with diluted Condy's fluid ; or with a solution of 
the sulpho-carbolate of zinc, of the strength of four grains to the 
ounce of Mater; or with plain tepid water. For obvious reasons fre- 
quent and strong vaginal douches are to be avoided, but a daily gentle 
injection, for the purpose of ablution, can do no harm. 

Pruritus. — A very distressing pruritus of the vulva is frequently 
met with along with leucorrhoea, especially when the discharge is of 
an acrid character, which in some cases leads to intense and protracted 
suffering, forcing the patient to resort to incessant friction of the parts. 
Pruritus, however, may exist without leucorrhoea, being apparently 
sometimes of a neuralgic character, at others associated with aphthous 
patches on the mucous membrane, asearides in the rectum, or pediculi 
in the hairs of the mons Veneris and labia. Cases are even recorded 
in which the pruritic irritation extended over the wdiole body. The 
treatment is difficult and unsatisfactory. Various sedative applications 
may be tried, such as weak solutions of Goulard's lotion ; or a lotion 
composed of an ounce of the solution of the muriate of morphia, with 
a drachm and a half of hydrocyanic acid, in six ounces of water ; or 
one formed by mixing one part of chloroform with six of almond oil. 
A verv useful form of medication consists in the insertion into the 
vagina of a pledget of cotton-wool, soaked in equal parts of the 
glycerin of borax and sulphurous acid ; this may be inserted at bed- 
time, and withdrawn in the morning bv means of a string attached to 
it. Smearing the parts with an ointment consisting of boracic acid 
and vaseline often answers admirably. Relief is also sometimes 
afforded by ichthyol ointment. In the more obstinate cases, the solid 
nitrate of silver may be lightly brushed over the vulva; or, as recom- 
mended by Tarnier, a solution of bichloride of mercury, of about the 
strength of two grains to the ounce, may be applied night and morning. 
The state of the digestive organs should always be attended to, and 
aperient mineral water may be usefully administered. When the pru- 
ritus extends beyond the vulva, or even in severe local cases, large 
doses of bromide of potassium may perhaps be useful in lessening the 
general hyperaesthetie state of the nerves. 

(Edema of the Lower Limbs. — Some of the disorders of preg- 
nancy are the direct results of the mechanical pressure of the gravid 

i Arch. gen. de Med.. 1856. 



222 PKEGNANCY. 

uterus. The most common of these are oedema and a varicose state of 
the veins of the lower extremities, or even of the vulva. The former 
is of little consequence, provided we have assured ourselves that it is 
really the result of pressure, and not of albuminuria, and it can gener- 
ally be relieved by rest in the horizontal position. A varicose state of 
the veins of the lower limbs is very common, especially in multipara?, 
in whom it is apt to continue after delivery. The varicosity is gener- 
ally limited to the superficial veins, chiefly the saphena, and the veins 
on the inner surface of the leg and thigh ; sometimes the deeper veins 
are also affected, and this is said to be accompanied by severe pain in 
the sole of the foot when the patient is standing or walking. Occa- 
sionally the veins of the vulva, and even of the vagina, are also 
enlarged and varicose, producing considerable swelling of the external 
•genitals. Rest in the recumbent position and the use of an abdominal 
belt, so as to take the pressure off the veins as much as possible, are 
all that can be done to relieve this troublesome complication. If the 
veins of the legs are much swollen some benefit may be derived from 
an elastic stocking or a carefully applied bandage. 

Laceration of the Veins. — Serious and even fatal consequences 
have followed the accidental laceration of the swollen veins. When 
laceration occurs during or immediately after delivery — a not uncom- 
mon result of the pressure of the head — it gives rise to the formation 
of a vaginal thrombus. It has occasionally happened from an acci- 
dental injury during pregnancy, as in the cases recorded by Simpson, 
in which death followed a kick on the pudenda, producing laceration 
of a varicose vein, or in one mentioned by Tarnier, where the patient 
fell on the edge of a chair. Severe hemorrhage has followed the acci- 
dental rupture of a vein in the leg. The only satisfactory treatment 
is pressure, applied directly to the bleeding parts by means of the 
finger, or by compresses saturated in a solution of the perchloride of 
iron. The treatment of vaginal thrombus following labor must be 
considered elsewhere. Occasionally the varicose veins inflame, become 
very tender and painful, and coagula form in their canals. In such 
cases absolute rest should be insisted on, while sedative lotions, such as 
the chloroform and belladonna liniments, should be applied to relieve 
the pain. 

Displacements of the Gravid Uterus. — Certain displacements of 
the gravid uterus are met with which may give rise to symptoms of 
great gravity. 

Prolapse, which is rare, is almost always the result of pregnancy 
occurring in a uterus which had been previously more or less procident. 
Under such circumstances the ' increasing weight of the uterus will at 
first necessarily augment the previously existing tendency to prolapse 
of the womb, which may come to protrude partially and entirely 
beyond the vulva. In the great majority of cases, as pregnancy 
advances, the prolapse cures itself, for at about the fourth or fifth 
month the uterus will rise above the pelvic brim. It has been said 
that in some cases of complete procidentia pregnancy has gone even 
to term > with the uterus lying entirely outside the vulva. Most prob- 
ably these cases were imperfectly observed, the greater part of the 



DISEASES OF PREGNANCY. 223 

uterus being in reality above the pelvic brim, a portion only of its 
lower segment protruding externally; or, as has sometimes been the 
ease, the protruding portion lias been an old-standing hypertrophic 
elongation of the cervix, the internal os uteri and fundus being nor- 
mally situated. Should a prolapsed uterus not rise into the abdominal 
cavity as pregnancy advances, serious symptoms will be apt to develop 
themselves; for, unless the pelvis be unusually capacious, the enlarging 
uterus will get jammed within its bony walls, the rectum and urethra 
will be pressed upon, defecation and micturition will be consequently 
impeded, and severe pain and much irritation will result. In all prob- 
ability such a state of things would lead to abortion. The possibility 
of these consequences should, therefore, teach us to be careful in the 
management of every case of prolapse, however slight, in which preg- 
nancy occurs. Absolute rest, in the horizontal position, should be 
insisted on ; while the uterus should be supported in the pelvis by a 
full-sized Hodge's pessary, which should be worn until at least the 
sixth month, when the uterus would be fully within the abdominal 
cavity. After delivery, prolonged rest should be recommended, in the 
hope that the process of involution may be accompanied by a cure of 
the prolapse. There can be no doubt that pregnancy carried to term 
aifords an opportunity of curing even old-standing displacements which 
should not be neglected. 

Anteversion of the gravid uterus seldom produces symptoms of 
consequence. In all probability it is common enough when pregnancy 
occurs in a uterus which is more than usually anteverted, or is ante- 
flexed. Under such circumstances, there is not the same risk of incar- 
ceration in the pelvic cavity as in cases in which pregnancy exists in a 
retroflexed uterus; for, as the uterus increases in size, it rises without 
difficulty into the abdominal cavity. In the early months the pressure 
of the fundus on the bladder may account for the irritability of that 
viscus then so commonly observed. It will be remembered that Graily 
Hewitt attributes great importance to this condition as explaining the 
sickness of pregnancy — a theory, however, which has not met with 
general acceptation. 

Extreme anteversion of the uterus, at an advanced period of preg- 
nancy, is sometimes observed in multiparae with very lax abdominal 
walls, occasionally to such an extent that the uterus falls completely 
forward and downward, so that the fundus is almost on a level with 
the patient's knees. This form of pendulous belly may be associated 
with a separation of the recti muscles, between which the womb forms 
a ventral hernia, covered only by the cutaneous textures. AVhen labor 
comes on, this variety of displacement may give rise to trouble by 
destroying the proper relation of the uterine and pelvic axes. The 
treatment is purely mechanical, keeping the patient lying on her back 
as much as possible, and supporting the pendulous abdomen by a prop- 
erly adjusted bandage. A similar forward displacement is observed 
in cases of pelvic deformity, and in the worst forms, in rhachitic and 
dwarfed women, it exists to a very exaggerated degree. 

Retroversion. — The most important of the displacements, in con- 
sequence of its occasional very serious results, is retroversion of the 



224 PREGNANCY. 

gravid uterus. It was formerly generally believed that this was most 
commonly produced by some accident, such as a fall, which dislocated 
a, uterus previously in a normal position. Undue distention of the 
bladder was also considered to have an important influence in its pro- 
duction, by pressing the uterus backward and downward. 

Causes. — It is now almost universally admitted that, although the 
above-named causes may possibly sometimes produce it, in the very 
large proportion of cases it depends on pregnancy having occurred in 
a uterus previously retroverted or retroflexed. The merit of pointing 
out this fact unquestionably belongs to the late Dr. Tyler Smith, and 
further observations have fully corroborated the correctness of his 
views. 

In the large majority of cases in which pregnancy occurs in a uterus 
so displaced, as the womb enlarges it straightens itself, and rises into 
the abdominal cavity, without giving any particular trouble ; or, as 
not unfrequently happens, the abnormal position of the organ inter- 
feres so much with its enlargement as to produce abortion. Sometimes, 
however, the uterus increases without leaving the pelvis until the third 
or fourth month, when it can no longer be retained in the pelvic cavity 
without inconvenience. It then presses on the urethra and rectum, 
and eventually becomes completely incarcerated within the rigid walls 
of the bony pelvis, giving rise to characteristic symptoms. 

Symptoms. — The first sign which attracts attention is generally 
some trouble connected with micturition, in consequence of pressure on 
the urethra. On examination the bladder will often be found to be 
enormously distended, forming a large, fluctuating abdominal tumor, 
which the patient has lost all power of emptying. Frequently small 
quantities of urine dribble away, leading the woman to believe that 
she has passed water, and thus the distention is often overlooked. 
Sometimes the obstruction to the discharge of urine is so great as to 
lead to dropsical effusion into the cellular tissue of the arms and legs. 
This Avas very well marked in one of my cases, and disappeared rapidly 
after the bladder had been emptied. Difficulty in defecation, tenesmus, 
obstinate constipation, and inability to empty the bowels, become estab- 
lished about the same time. These symptoms increase, accompanied by 
some pelvic pain, and a sense of weight and bearing down, until at last 
the patient applies for advice, and the true nature of the case is detected. 
When the retroversion occurs suddenly, all these symptoms develop 
with great rapidity, and are sometimes very serious from the first. 

Progress and Termination. — The further progress is various. 
Sometimes, after the uterus has been incarcerated in the pelvis for 
more or less time, it may spontaneously rise into the abdominal cavity, 
when all threatening symptoms will disappear. So happy a termina- 
tion is quite exceptional, and should the practitioner not interfere and 
effect reposition of the organ, serious and even fatal consequences may 
ensue, unless abortion occurs. 

The extreme distention of the bladder, and the impossibility of 
relieving it, may lead to lacerations of its coats and fatal peritonitis ; 
or the retention of urine may produce cystitis, with exfoliation of the 
coats of the bladder ; or, as more commonly happens, retention of 



DISEASES OF PREGNANCY. 225 

urinary elements may take place, and death occur with all the symp- 
toms of uremic poisoning. At other times the impacted uterus 
becomes congested and inflamed, and eventually sloughs, its contents, 
it' the patient survive, being discharged by fistulous communications 

into the rectum and vagina. It need hardly be said that such termi- 
nations are only possible in eases which have been grossly mismanaged, 
or the nature of which has not been detected till a late period. 

Diagnosis. — The diagnosis is not difficult. On making a vaginal 
examination, the finger impinges on a smooth round elastic swelling, 
tilling* up the lower part of the pelvis, stretching and depressing the 
posterior vaginal wall, which occasionally protrudes beyond the; vulva. 
On passing the finger forward and upward we shall generally be able 
to reach the cervix, high up behind the pubes, and pressing on the 
urethral canal. In very complete retroversion it may be difficult or 
impossible to reach the cervix at all. On abdominal examination the 
fundus uteri cannot be felt above the pelvic brim ; this, as the retro- 
version does not give rise to serious symptoms until between the third 
and fourth months, should, under natural circumstances, always be 
possible. By bimanual examination we can make out, with due care, 
the alternate relaxation and contraction of the uterine parietes char- 
acteristic of the gravid uterus, and so differentiate the swelling from 
any other in the same situation. The accompanying phenomena of 
pregnancy will also prevent any mistake of this kind. 

In some few cases retroversion has been supposed to go on to term. 
Strictly speaking, this is impossible ; but in the supposed examples, 
such as the well-known case recorded by Oldham, part of a retroflexed 
uterus remained in the pelvic cavity, while the greater part developed 
in the abdominal cavity. The uterus is, therefore, divided, as it were, 
into two portions : one, which is the flexed fundus, remaining in the 
pelvis, the other, containing the greater part of the foetus, rising above 
it. Under these circumstances, a tumor in the vagina would exist in 
combination with an abdominal tumor, and pregnancy might go on to 
term. Considerable difficulty may even arise in labor, bnt the mal- 
position generally rectifies itself before it gives rise to any serious 
results. 

Treatment. — The treatment of retroversion of the gravid uterus 
should be taken in hand as soon as possible, for every day's delay 
involves an increase in the size of the uterus, and leads, therefore, to 
greater difficulty in reposition. Our object is to restore the natural 
direction of the uterus, by lifting the fundus above the promontory 
of the sacrum. The first thing to be done is to relieve the patient by 
emptying the bladder, the retention of urine having probably originally 
called attention to the case. For this purpose it is essential to use a 
long elastic male catheter of small size, as the urethra is too elongated 
and compressed to admit of the passage of the ordinary silver instru- 
ment. Even then it may be extremely difficult to introduce the 
catheter, and sometimes it has been found to be quite impossible. 
Under such circumstances, provided reposition cannot be effected 
without it, the bladder may be punctured an inch or two above the 
pubes by means of the fine needle of an aspirator, and the urine drawn 

15 



226 PREGNANCY. 

off. Dieuiafoy's work on aspiration proves conclusively that this may 
be done without risk, and the operation has been successfully performed 
by Sckatz and others. It very rarely happens, however, and in long- 
neglected cases only, that the withdrawal of the urine is found to be 
impossible. 

The bladder being emptied, and the bowels being also opened, if 
possible, by copious enemata, we proceed to attempt reduction. For 
this purpose various procedures are adopted. If the case is not of very 
long standing, I am inclined to think that the gentlest and safest plan 
is the continuous pressure of a caoutchouc bag, filled with water, placed 
in the vagina. The good effect of steady and long-continued pressure 
of this kind was proved by Tyler Smith, who effected in this way the 
reduction of an inverted uterus of long standing, and it is not difficult 
to understand that it may succeed when a more sudden and violent 
effort fails. I have tried this plan successfully in several cases, a 
pvriform India-rubber bag being inserted into the vagina and dis- 
tended as far as the patient could bear by means of a syringe. The 
water must be let out occasionally to allow the patient to empty the 
bladder, and the bag immediately refilled. In my cases reposition 
occurred within twenty-four hours. Barnes has failed with this 
method ; but it succeeded so well in my cases, and is so obviously less 
likely to prove hurtful than forcible reposition with the hand, that 
I am inclined to consider it the preferable procedure, and one that 
should be tried first. Failing with the fluid pressure, we should 
endeavor to replace the uterus in the following way. The patient 
should be placed at the edge of the bed, in the ordinary obstetric posi- 
tion, and thoroughly anaesthetized. This is of importance, as it relaxes 
all the parts, and admits of much freer manipulation than is otherwise 
possible. One or more fingers of the left hand are then inserted into 
the rectum ; if the patient be deeply chloroformed, it is quite possible, 
with due care, even to pass the whole hand, and an attempt is then 
made to lift or push the fundus above the promontory of the sacrum. 
At the same time reposition is aided by drawing down the cervix with 
the fingers of the right hand per vaginam. It has been insisted that 
the pressure should be made in the direction of one or other sacro-iliac 
synchondrosis rather than directly upward, so that the uterus may not 
be jammed against the projection of the promontory of the sacrum. 
Failing reposition through the rectum, an attempt may be made per 
vaginam, and for this some have advised the upward pressure of the 
closed fist passed into the canal. Others recommend the hand-and- 
knee position as facilitating reposition, but this prevents the adminis- 
tration of chloroform, which is of more assistance than any change of 
position can possibly be. Various complex instruments have been 
invented to facilitate the operation, but they are all more or less 
dangerous, and are unlikely to succeed when manual pressure has failed. 

As soon as the reduction is accomplished, subsequent descent of the 
uterus should be prevented by a large-sized Hodge's pessary, and the 
patient should be kept at rest for some days, the state of the bladder 
and bowels being particularly attended to. When reposition has been 
fairly effected a relapse is unlikely to occur. 



DISEASES OF PREGNANCY. 227 

In cases in which reduction is found to be impossible, cur only 
resource is the artificial induction of abortion. Under such circum- 
stances this is imperatively called for. It is best effected by puncturing 
the membranes, the discharge of the liquor amnii of itself Lessening 
the size of the uterus, and thus diminishing the pressure to which the 
neighboring parts are subjected. After this, reposition may he possible, 
or we may wait until the foetus is spontaneously expelled. It is uol 
always easy to reach the os uteri, although we can generally do so with 
a curved uterine sound. If we cannot puncture the membranes, the 
liquor amnii may be drawn off through the uterine walls by means of 
the aspirator, inserted through either the rectum or vagina. The 
injury to the uterine walls thus inflicted is not likely to be hurtful, and 
the risk is certainly far less than leaving the case alone. Naturally, so 
extreme a measure would not be adopted until all the simpler means 
indicated have been tried and failed. 

Diseases Coexisting- "with Pregnancy. — The pregnant woman is, 
of course, liable to contract the same diseases as in the non-pregnant 
state, and pregnancy may occur in women already the subject of some 
constitutional disease. There is no doubt much yet to be learned as 
to the influence of coexisting disease on pregnancy. It is certain that 
some diseases are but little modified by pregnancy, and that others are 
so to a considerable extent ; and that the influence of the disease on 
the foetus varies much. The subject is too extensive to be entered 
into at any length, but a few words may be said as to some of the 
more important affections that are likely to be met with. 

The eruptive fevers have often very serious consequences, propor- 
tionate to the intensity of the attack. Of these variola has the most 
disastrous results, which are related in the writings of the older 
authors, but which are, fortunately, rarely seen in these days of 
vaccination. The severe and confluent forms of the disease are almost 
certainly fatal to both the mother and child. In the discrete form, 
and in modified smallpox after vaccination, the patient generally has 
the disease favorably, and although abortion frequently results, it does 
not necessarily do so. The effects on the children vary. The foetus 
may escape the disease altogether ; or it may be attacked by it either 
before or after birth ; or, if the mother has had smallpox during preg- 
nancy, the child maybe subsequently insusceptible to the vaccine virus. 

Scarlet Fever. — If scarlet fever of an intense character attacks a 
pregnant woman, abortion is likely to occur, and the risks to the 
mother are very great. The milder cases run their course without 
the production of any untoward symptoms. Should abortion occur, 
the well-known dangerous effect of this zymotic disease after delivery 
will gravely influence the prognosis. Cazeaux was of opinion that preg- 
nant women are not apt to contract the disease. It has been thought 
that the poison when absorbed during pregnancy might remain latent 
until delivery, when its characteristic effects were produced. It is 
certainly more common after delivery than during pregnancy ; thus 
Olshausen 1 collected one hundred and thirty-five cases of the former 
kind, and only seven of the latter. 

1 Arch. f. Gynak., 1877. Bd. ix. S. 111. 



228 PREGNANCY. 

Measles. — Measles, unless very severe, often runs its course without 
seriously affecting the mother or child. I have myself seen several 
examples of this. De Tourcoing, however, states that out of fifteen 
cases the mother aborted in seven, these being all very severe attacks. 
Some cases are recorded in which the child was born with the rubeolous 
eruption upon it. 

Continued Fevers. — The pregnant woman may be attacked with 
any of the continued fevers, and if they are at all severe, they are apt 
to produce abortion. Out of twenty-two cases of typhoid, sixteen 
aborted, and the remaining six, who had slight attacks, went on to 
term ; out of sixty-three cases of relapsing fever, abortion or premature 
labor occurred in twenty-three. According to Schweden the main 
cause of danger to the fetus in continued fevers is the hyperpyrexia, 
especially when the maternal temperature reaches 104° or upward. 
The fevers do not appear to be aggravated as regards the mother, and 
the same observation has been made by Cazeaux with regard to this 
class of disease occurring after delivery. 

Pneumonia. — Pneumonia seems to be specially dangerous, for of 
fifteen cases collected by Grisolle 1 eleven died — a mortality immensely 
greater than that of the disease in general. The larger proportion 
also aborted, the children being generally dead, and the fatal result is 
probably due, as in the severe continued fevers, to hyperpyrexia. The 
cause of the maternal mortality does not seem quite apparent, since 
the same danger does not appear to exist in severe bronchitis, or other 
inflammatory affections. 

Phthisis. — Contrary to the usually received opinion, it appears 
certain that pregnancy has no retarding influence on coexisting 
phthisis, nor does the disease necessarily advance with greater rapidity 
after delivery. Out of twenty-seven cases of phthisis, collected by 
Grisolle, twenty-four showed the first symptoms of the disease after 
pregnancy had commenced. Phthisical Avomen are not apt to con- 
ceive ; a fact which may probably be explained by the frequent 
coexistence, in such cases, of uterine disease, especially severe leucor- 
rhoea. The entire duration of the phthisis seems to be shortened, as 
it averaged only nine and a half months in the twenty-seven cases 
collected — a fact which proves, at least, that pregnancy has no material 
influence in arresting its progress. If we consider the tax on the vital 
powers which pregnancy naturally involves, we must admit that this 
view is more physiologically probable than the one generally received, 
and apparently adopted without any due grounds. 

Heart Disease. — The evil effects of pregnancy and parturition on 
chronic heart disease have of late received much attention from 
Spiegelberg, Fritsch, Peter, and other writers. The subject has been 
ably discussed 2 in a series of elaborate papers by Dr. Angus Mac- 
donald, which are well worthy of study. Out of twenty-eight cases 
collected by him, seventeen, or 60 per cent., proved fatal. This, no 
doubt, is not altogether a reliable estimate of the probable risk of the 

1 Arch. gen. de Med., vol. xiii. p. 291. 

2 Obst. Journ., 1877, vol. v. p. 217. 



DISSASSS OF PREGNANCY. 229 

complication ; but, at any rate, it shows the serious anxiety which the 
occurrence of pregnancy in a patient suffering from chronic heart 
disease must cause. Dr. Macdonald refers the evils resulting from 
pregnancy in connection with cardiac lesions to two causes : first, 
destruction of that equilibrium of the circulation which has been 
established by compensatory arrangements ; secondly, the occurrence 
of fresh inflammatory lesions upon the valves of the heart already 
diseased. 

The dangerous symptoms do not usually appear until after the first 
half of the pregnancy has passed, and the pregnancy seldom advances 
to term. The pathological phenomena generally met with in fatal 
cases are pulmonary congestion, especially of the bronchial mucous 
membrane, and pulmonary oedema, with occasional pneumonia and 
pleurisy. Mitral stenosis seems to be the form of cardiac lesion most 
likely to prove serious, and, next to this, aortic incompetency. The 
obvious deduction from these facts is that heart disease, especially 
when associated with serious symptoms, such as dyspnoea, palpitation, 
and the like, should be considered a strong eontra-indication of 
marriage. When pregnancy has actually occurred, all that can be 
done is to enjoin the careful regulation of the life of the patient, so as 
to avoid exposure to cold, and all forms of severe exertion. 

Syphilis. — The important influence of syphilis on the ovum is 
fully considered elsewhere (p. 248). As regards the mother, its effects 
are not different from those occurring at other times. It need only, 
therefore, be said that, whenever indications of syphilis in a pregnant 
woman exist, the appropriate treatment should be at once instituted and 
carried on during her gestation, not only with the view of checking 
the progress of the disease, but in the hope of preventing or lessening 
the risk of abortion, or of the birth of an infected infant. So far from 
pregnancy contra-indicating mercurial treatment, there rather is a 
reason for insisting on it more strongly. As to the precise medication, 
it is advisable to choose a form that can be exhibited continuously for 
a length of time without producing serious constitutional results. 
Small doses of the bichloride of mercury, such as one-sixteenth of a 
grain, thrice daily, or of the iodide of mercury, or of the hydrargyrum 
cum creta, in combination with reduced iron, answer the purpose 
well ; or, in the early stages of pregnancy, the mercurial vapor bath, 
or cutaneous inunction, may be employed. 

Dr. Weber, of St. Petersburg, 1 has made some observations showing 
the superiority of the latter methods, which he found did not interfere 
with the course of pregnancy ; the contrary was the case when the 
mercury was administered by the mouth, probably, as he supposes, 
from disturbance of the digestive system. It must be borne in mind 
that in married women it may sometimes be expedient to prescribe an 
anti-syphilitic course without their knowledge of its nature, so that 
inunction is not always feasible. 

Epilepsy. — The influence of pregnancy on epilepsy does not appear 
to be as uniform as might perhaps be expected. In some cases the 

> Allgem. Med. Centr. Zeit., Feb. 1 



230 PREGXAXCY. 

number and intensity of the fits have been lessened, in others the dis- 
ease becomes aggravated. Some cases are even recorded in which 
epilepsy appeared for the first time during gestation. On account of 
the resemblance between epilepsy and eclampsia there is a natural 
apprehension that a pregnant epileptic may suffer from convulsions 
during delivery. Fortunately, this is by no means necessarily the 
case, and labor often goes on satisfactorily without any attack. 

Diseases of the Eye. — Certain diseases of the eye are observed 
during pregnancy. They have been well studied by Mr. Power. 1 One 
of the most common disturbances of vision is due to temporary im- 
pairment of accommodation, most generally in patients who are natur- 
ally hypermetropic, and dependent on exhaustion of the neuro-muscular 
apparatus. The symptoms are chiefly difficulty in reading, sewing, or 
other work requiring minute vision ; pain, black spots before the eyes, 
lachrymation, etc. Suitable convex glasses may be required, and with 
attention to the general health the symptoms may disappear. Other 
diseases more serious and lasting in their results are also met with. 
Mr. Power describes certain important changes in the eye met with in 
cases of albuminuria. The optic disk is swollen and congested, and 
irregular hemorrhages and white disks are seen in the retina. The 
hemorrhages he ascribes to actual rupture of the vessels; the white 
patches to a lesser degree of distention, admitting of the escape of 
white corpuscles through the vascular Avails. In many of these cases 
the vision was ultimately regained. Another form of disease he de- 
scribes is " white atrophy of the optic disk/' probably following neu- 
ritis, occurring in cases in which there had been great loss of blood. 

Simple jaundice, having little serious effect on the mother, although 
probably tending to produce abortion, is occasionally met with in 
pregnancy. Such attacks may be transient, and may pass away with- 
out being attended with any bad consequence. Their production is 
probably favored by a slight degree of parenchymatous infiltration of 
the liver, which is a normal accompaniment of healthy pregnancy, as 
well as by the mechanical pressure of the gravid uterus on the intes- 
tines and the bile-ducts. Their symptoms do not differ from those of 
similar attacks in the nonpregnant state. 

The chief anxiety in regard to jaundice in pregnant women is that 
it is the frequent precursor of the serious disease known as "acute 
yellow atrophy of the liver," which is, as a matter of fact, a misnomer, 
the disease being a general one, of which the liver changes, though 
marked, are by no means an exclusive manifestation. 

Into the pathology and .symptoms of this fatal illness it would be 
out of place to enter here at length. It is chiefly of moment to the 
obstetrician from the fact that it is undoubtedly more common in preg- 
nant women than in others. This is to be explained partly by the 
parenchymatous changes in the liver natural to pregnancy, partly to 
the impaired action of the kidneys, and to the altered state of the 
blood met with in that condition, the general toxa?mia, characteristic 
of the disease, being ultimately increased by the retention of the bile- 

1 Barnes : Obst. Med., vol. i. p. 390. 



DISEASES OF PREGNANCY. 231 

products. The prognosis, as regards the mother, is as bad as anything 
ran be, very few cases, and these of a doubtful character, having re- 
covered. As regards the foetus, the issue is also almost necessarily 
fatal, and it has been noted that while the foetus perishes early iu the 

course of the illness, there is not the same tendency for the uterus to 
throw off its contents which is observed in other conditions in which 
the ovum is destroyed, but that the dead and macerated foetus is retained 
in utero. 

The important point to decide in a suspected case is as to whether 
means should be taken to put an end to the pregnancy or not. This 
would appear to be a reasonable procedure, since the toxic conditions 
of the blood must go on increasing pari passu with pregnancy. Even 
this, however, is of doubtful expediency, for it has beeu observed that 
previously existing symptoms have become intensified after abortion, 
possibly from the increased weakness resulting from the hemorrhage 
accompanying it.' 

Carcinoma. — The occurrence of pregnancy in a woman suffering 
from malignant disease of the uterus is by no means so rare as might 
be supposed, and must naturally give rise to much anxiety as to the 
result. The obstetrical treatment of these cases will be discussed else- 
where. Should we be aware of the existence of the disease during 
gestation, the question will arise whether we should not attempt to 
lessen the risks of delivery by bringing on abortion or premature 
labor. The epiestion is one which is by no means easy to settle. We 
have to deal with a disease which is certain to prove fatal to the mother 
before long, and the progress of which is probably accelerated after 
labor, Avhile the manipulations necessary to induce delivery may very 
unfavorably influence the diseased structures. Again, by such a 
measure we necessarily sacrifice the child, while we are by no means 
certain that we materially lessen the danger to the mother. The ques- 
tion cannot be settled except on a consideration of each particular case. 
If we see the patient early in pregnancy, by inducing abortion we may 
save her the dangers of labor at term — possibly of the Cesarean sec- 
tion — if the obstruction be great. Under such circumstances, the 
operation would be justifiable. If the pregnancy has advanced beyond 
the sixth or seventh month, unless the amount of malignaut deposit be 
very small indeed, it is probable that the risks of labor would be as 
great to the mother as at term, and it would then be advisable to give 
her the advantage of the few months' delay. If the malignant growth 
is of the epithelial variety, and limited to the cervix, it might in some 
cases be advisable to operate on it by amputating the cervix xvitli the 
ecraseur or galvano-caustic wire. This would probably be followed 
by abortion, Avhich, under such conditions, would not be a disadvantage 
to the mother. 

Ovarian Tumor. — Cases are occasionally met with in which preg- 
nancy occurs in. women who are suffering from ovarian tumor, and 
their proper management has given rise to considerable discussion. 
There can be no doubt that such cases are attended with very danger- 

i Lusk's Midwifery, 4th edition, p. 2G0. 



232 PREGNANCY. 

oils and often fatal consequences, for the abdomen cannot well accom- 
modate the gravid uterus and the ovarian tumor, both increasing 
simultaneously. The result is that the tumor is subject to much con- 
tusion and pressure, which have sometimes led to the rupture of the 
cyst, and the escape of its contents into the peritoneal cavity ; at others 
to a low form of inflammation, attended with much exhaustion, the 
death of the patient supervening either before or shortly after delivery. 
The danger during delivery from the same cause, in the cases which 
go on to term, is also very great. Of thirteen cases of delivery by the 
natural powers, which I collected in a paper on " Labor Complicated 
with Ovarian Tumor/' l far more than one-half proved fatal. Another 
source of danger is twisting of the pedicle, and consequent strangula- 
tion of the cyst, of which several instances are recorded. It is obvious, 
then, that the risks are so manifold that in every case it is advisable to 
consider whether they can be lessened by surgical treatment. 

The means at our disposal are either to induce labor prematurely, to 
treat the tumor by tapping, or to perform ovariotomy. The question 
has been particularly discussed by Spencer AVells in his works on 
Ovariotomy, and by Barnes in his Obstetric Operations. The former 
holds that the proper course to pursue is to tap the tumor when there 
is any chance of its being materially lessened in size by that procedure, 
but that when it is multilocular, or when its contents are solid, ovari- 
otomy should be performed at as early a period of pregnancy as pos- 
sible. Barnes, on the other hand, maintains that the safer course is to 
imitate the means by which Nature often meets this complication, and 
bring on premature labor without interfering with the tumor. He 
thinks that ovariotomy is out of the question, and that tapping may 
be insufficient and leave enough of the tumor to interfere seriouslv 

CD . 

Avith labor. So far as recorded cases go, they unquestionably seem to 
show that tapping is not more dangerous than at other times, and that 
ovariotomy may be practised during pregnancy with a fair amount of 
success. Wells records ten cases which were surgically interfered with. 
In one, tapping was performed, and in nine ovariotomy ; and of these 
eight recovered, the pregnancy going on to term in five. On the other 
hand, five cases were left alone, and either went to term, or spontaneous 
premature labor supervened ; and of these, three died. The cases are not 
sufficiently numerous to settle the question, but they certainly favor 
the view taken by AVells rather than that by Barnes. It is to be 
observed that, unless we give up all hope of saving the child, and 
induce abortion, the risk of induced premature labor, when the preg- 
nancy is sufficiently advanced to hope for a viable child, would almost 
be as great as that of labor at term ; for the question of interference 
will only have to be considered with regard to large tumors, Avhich 
would be nearly as much affected by the pressure of a gravid uterus 
at seven or eight months as by one at term. Small tumors generally 
escape attention, and are more apt to be impacted before the presenting 
part in delivery. The success of ovariotomy during pregnancy has 
certainly been great, and we have to bear in mind that the woman 

1 Obst. Trans., 1867, vol. ix. p. 69. 



DISEASES OF PREGNANCY. 233 

must necessarily be subjected to the risk of the operation sooner or 
later, so that we cannot judge of the case as one in which abortion 
terminates the risk. Even if the operation should put an end to the 

pregnancy— and there is at least a fair chance that it will not do so — 
there is no certainty that that would increase the risk of the operation 
to the mother, while as regards the child we should only have the same 
result as if we intentionally produced abortion. On the whole, then, 
it seems that the best chance to the mother, and certainly the best to 
the child, is to resort to the apparently heroic practice recommended 
by Wells. The determination must, however, be to some extent influ- 
enced by the skill and experience of the operator. If the medical 
attendant has not gained that experience which is so essential for a 
successful ovariotomist, the interests of the mother would be best con- 
sulted by the induction of abortion at as early a period as possible. 
One or other procedure is essential ; for, in spite of a few cases in 
which several successive pregnancies have occurred in women who 
have had ovarian tumors, the risks are such as not to justify an ex- 
pectant practice. Should rupture of the cyst occur, there can be no 
doubt that ovariotomy should at once be resorted to, with the view of 
removing the lacerated cyst and its extra vasated contents. 

Fibroid Tumors. — Pregnancy may occur in a uterus in which there 
are one or more fibroid tumors. During pregnancy they may lead to 
premature labor or abortion, to peritonitis, or they may cause so much 
pain and discomfort from their size as to render interference imperative. 
If they are situated low down, and in a position likely to obstruct the 
passage of the foetus, they may very seriously complicate delivery. 
AYhen they are situated in the fundus or body of the uterus they may 
give rise to risk from hemorrhage, or from inflammation of their own 
structure. Inasmuch as they are structurally similar to the uterine 
walls, they partake of the grow r th of the uterus during pregnancy, and 
frequently increase remarkably in size. Cazeaux says : " I have known 
them in several instances to acquire a size in three or four months which 
they would not have done in several years in the non-pregnant condi- 
tion. " Conversely, they share in the involution of the uterus after 
delivery, and often lessen greatly in size, or even entirely disappear. 
Of this fact I have elsewhere recorded several curious examples ; l and 
many other instances of the complete disappearance of even large 
tumors have been described by authors whose accuracy of observation 
cannot be questioned. 

The treatment will vary with the size and position of the tumor, and 
every case must be treated on its own merits, since it is not possible to 
lay down rules that will apply to all cases alike. A full report of all 
recent cases Avill be found in Dr. John Phillips's 2 paper, which shows 
how serious the results often are. If the position of the tumor be such 
as to to render it certain to obstruct delivery, the production of early 
abortion is perhaps the best course to pursue. It is not without serious 
risks, but probably less than allowing pregnancy to proceed to term. 

1 Obst. Trans.. 1869, vol. x. p. 102 ; 1872, vol. xiii. p. 288 ; 1877, vol. xix. p. 101. 

2 •• The Management of Fibro-myomata complicating Pregnancy and Labor." Brit. Med. Jonrn., 
1888, vol. i. p. 1331. 



234 PREGNANCY. 

In several instances, either the removal of the tumor itself by abdom- 
inal section (myomectomy), or the removal of the tumor and the gravid 
uterus (Porro's operation), has been resorted to on account of the grave 
concomitant symptoms, and with a fair measure of success. If the 
tumor is well out of the way, interference is not so urgently called 
for. The principal danger then is that the tumor will impede the post- 
partum contraction of the uterus, and favor hemorrhage. Even if this 
should happen, the flooding could be controlled by the usual means, 
especially by the injection of the perchloride of iron. I have seen 
several cases in which delivery has taken place under such circum- 
stances without any untoward accident. The danger from inflamma- 
tion and subsequent extrusion of the fibroid masses would probably be 
as great after abortion or premature labor as after delivery at term. It 
seems, therefore, to be the proper rule to interfere when the tumors are 
likely to impede delivery, and in other cases to allow the pregnancy to 
go on, and be prepared to cope with any complications as they arise. 
The risks of pregnancy should be avoided in every case in which 
uterine fibroids of any size exist, the patients being advised to lead a 
celibate life. 



CHAPTEE IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua. — Comparatively little is, unfortunately, 
known of the pathological changes which occur in the mucous mem- 
brane of the uterus during pregnancy. It is probable that they are of 
much more consequence than is generally believed to be the case ; and 
it is certain that they are a frequent cause of abortion. 

One of the most generally observed probably depends on endome- 
tritis antecedent to conception. When the impregnated ovule reached 
the uterus, it engrafted itself on the inflamed mucous membrane, 
which was in an unfit condition for its reception and growth. A not 
uncommon result, under such circumstances, is the laceration of some 
of the decidual vessels, extravasation of the blood between the decidua 
and the uterine walls, and consequent abortion at an early stage of 
pregnancy. As this morbid state of the uterine mucous membrane is 
likely to continue after abortion is completed, the same history repeats 
itself on each impregnation, and thus we may have constant early mis- 
carriages produced. It does not necessarily follow, however, that the 
pregnancy is immediately terminated when this state of things is 
present. Sometimes a condition of hyperplasia of the decidua is pro- 
duced, the membrane becomes much thickened and hypertrophied in 
consequence of proliferation of its interstitial connective tissue, and 



PATHOLOGY OF TDK DEC IDT A AND OVUM 



235 



the decidual cells are greatly Increased in size (Fig. 90). In oilier 
instances the internal surface of the decidua becomes studded with 
rough polypoid growths, 1 depending on proliferation of its interstitial 

tissue, u condition described as endometritis decidualia polyposci, or 
tuberosa. Duncan 1ms found that the hypertrophied decidua is always 
in a state of fatty degeneration, more advanced in some places than in 

others. 2 The result of these alterations is frequently to produce 
dwindling or death of the ovum, which, however, retains its connection 

O 7 7 7 

Fig. 90. 




Hypertrophied decidua laid open, with the ovum attached to its fundal portion. 
(After Duncan.) 



with the decidua, until, after a lapse of time, the decidua is expelled in 
the form of a thick triangular fleshy substance, with the atrophied 
ovum attached to some part of its inner surface. In other cases, in 
which the hyperplasia has advanced to a less extent, the nutrition of 
the foetus is not interfered with, and pregnancy may continue to term, 
the changes in the decidua being recognizable after delivery. Other 
diseases besides endometritis may give rise to similar alterations in the 
decidua, one of these being, as Virchow maintains, syphilis. The 
converse condition, an imperfect development of the decidua, especially 
of the decidua reflexa, has also been noted as a cause of abortion. The 



1 Virchow's Archiv far Path., 1861, 1st edit. 
8 Researches in Obstetrics, p. 293. 



236 PREGNANCY. 

ovum will then hang loosely in the uterine cavity without the support 
which the growth of the clecidua reflexa around it ought to afford, and 
its premature expulsion readily follows (Fig. 91). 

Fig. 91. 







Imperfectly developed decidua vera, with the ovum. (After Duncan.) 

Hydrorrhea Gravidarum. — The peculiar condition known as 
hydrorrhea gravidarum most probably depends on some obscure mor- 
bid state of the uterine mucous membrane. By it is meant a discharge 
of clear watery fluid at intervals during pregnancy. It may happen 
at any period of gestation, but it is most commonly met with in the 
latter months. It may commence with a mere dribbling, or there may 
be a sudden and copious discharge of fluid. Afterward the watery 
fluid, which is generally of a pale-yellowish color and transparent like 
the liquor amnii, may continue to escape at intervals for many weeks, 
and sometimes in very great abundance, so as to saturate the patient's 
clothes. Very frequently it is expelled in gushes, and at night, when 
the patient is lying quietly in bed ; its escape is then probably due to 
uterine contraction. 

Many theories have been held as to its cause. By some it is 
attributed to the rupture of a cyst placed between the ovum and the 
uterine walls ; Baudelocque referred it to a transudation of the liquor 
amnii through the membranes ; while Burgess and Dubois believed it 
to depend on a laceration of the membranes at a distance from the os 
uteri. Mattei more recently has attributed it to the existence of a sac 
between the chorion and the amnion. It may be that in some instances 
a single discharge of fluid may come from one of the two last- 
mentioned causes. But if it be continuous, or repeated, another source 
must be sought for.. Hegar 1 maintains that it is the result of abun- 
dant secretion from the glands of the mucous membrane, which are in 
a state of chronic inflammation, the fluid accumulating between the 

1 Monat. f. Geburt., 1863, Bd. xxii. S. 429. 



A.THOLOGY OF THE DECIDUA AND OVUM. 



237 



Fig. 92, 



decidua and chorion, and escaping through the os uteri, [f this occur 
the decidua is probably in an hypertrophied and otherwise nun-hid 
state. Hydrorrhoea is chiefly of interest from the error of diagnosis to 
which it is likely to give rise; for, on being summoned to a case in 
which watery discharge has occurred for the firsttime, we are naturally 
apt to suppose thai the membranes have ruptured, and that labor is 
imminent. Nor is there any very certain means of deciding if this 
be so. In hydrorrhoea, we find that pains are absent, the os uteri 
unopened, and hallottement may be made out. Even if the mem- 
branes be ruptured, there will be no indication for interference unless 
labor has actually commenced ; and the repetition of the discharge and 
the continuance of the pregnancy will soon clear up the diagnosis. 
Hydrorrhoea, although apt to alarm the patient, need not give rise to 
any anxiety. The pregnancy generally progresses favorably to the 
full period, although in exceptional cases premature labor may super- 
vene. No treatment is necessary, nor is there any that could have 
the least etfect in controlling the discharge. 

Patholog-y of the Chorion. — The only important disease of the 
chorion with which Ave are acquainted is the well-known condition 
which is variously described as uterine hydatids, cystic disease of the 
ovum, hydatidiform degeneration of the chorion, or vesicular mole. The 
name of uterine hydatids was long given to it on the supposition that 
the grape-like vesicles which characterize 
the disease were true hydatids, similar to 
those which develop in the liver and other 
structures. This idea has long been ex- 
ploded, and it is now known as a certainty 
that the disease originates in the villi of 
the chorion. The precise mode and the 
causes of its production are, however, not 
yet satisfactorily settled. The disease is 
characterized by the existence in the cavity 
of the uterus of a large number of trans- 
lucent vesicles, containing a clear limpid 
fluid which has been found on analysis to 
bear close resemblance to the liquor amnii. 
These small bladder-like bodies, which 
vary in size from that of a millet-seed to 
an acorn, are often described as resembling 
a bunch of grapes or currants. On more 
minute examination, they are found not to 
be each attached to independent pedicles, 
as is the case in a bunch of grapes, but some 
of them grow from other vesicles, while 
others have distinct pedicles attached to 
th chorion, the pedicles themselves some- 
times being distended by fluid (Fig. 92). 

This peculiar arrangement of the vesicles is explained by their mode 
of growth. 

Causes. — There has been considerable discussion as to the etiology 




Hydatidiform degeneration of the 
chorion. 



238 PREGNANCY. 

of this disease. By some it is supposed always to follow death of the 
foetus; and the whole developmental energy being expended on the 
chorion, which retains its attachment to the decidua, the result is its 
abnormal growth and cystic degeneration. This is the view main- 
tained by Gierse and Graily Hewitt, and it is favored by the un- 
doubted fact that in almost all cases the foetus has entirely disappeared, 
and by the occasional occurrence of cases of twin conceptions in which 
one chorion has degenerated, the other remaining healthy until term. 
On the other hand, it is maintained that the starting-point is connected 
with the maternal organism. "Virchow thinks it originates in a morbid 
state of the decidua ; virile others have attributed it to some blood 
dyscrasia on the part of the mother, such as syphilis. There are 
many reasons for believing that causes of this nature may originate 
the affection. Thus it is often found to occur more than once in the 
same person ; and alterations of a similar kind, although limited in 
extent, are not unfrequently found in connection with the placenta 
and membranes of living children. On this theory the death of the 
foetus is secondary, the consequence of impaired nutrition from the 
morbid state of the chorion. The probability is that both views may 
be right, the disease sometimes following the death of the embryo, aud 
at others being the result of obscure maternal causes. 

Pathology. — The degeneration of the chorion villi generally com- 
mences at an early period of pregnancy, before the placenta has 
commenced to form. In that case, the entire superficies of the chorion 
becomes affected. The disease, however, may not begin until after the 
greater part of the chorion villi have atrophied, and then it is limited 
to the placenta. The epithelium of the villi appears to be the part first 
affected, and the whole interior of the diseased villus becomes filled 
with cells. The connective tissue of the villus undergoes a remarkable 
proliferation, and collects in masses in individual spots, the remainder 
of the villus being unaffected. Bv the growth of these elements the 
villus becomes distended, and many of the cells liquify, the intercel- 
lular fluid, thus produced, widely separating the connective tissue, so 
as to form a network in the interior of the villus. 1 Thus are formed 
the peculiar grape-like bodies which characterize the disease. When 
once the degeneration has commenced, the diseased tissue has a re- 
markable power of increase, so that it sometimes forms a mass as large 
as a child's head, and several pounds in weight. 

The nutrition of the altered chorion is maintained by its connection 
with the decidua, which is also generally diseased and hypertrophied. 
Sometimes the adhesion of the mass to the uterine walls is very firm, 
and may interfere with its expulsion ; while, in a few rare cases, it has 
been found that the villi have forced their way into the substance of 
the uterus, chiefly through the uterine sinuses, and thus caused atrophy 
and thinning of its muscular structure. Cases of this kiud are related 
by Volkmann, AValdeyer, 2 and Barnes, and it is obvious that the 
intimate adhesion thus effected must seriously add to the gravity of 
the prognosis. 

1 Braxton Hicks : Guy's Hospital Reports, vol. ii., 3d series, p. 380. 

2 Virchow's Archiv, vol. xliv. p. 86. 



PATHOLOGY OF THE DKCIDUA AND OVUM. 

Taking this view of the etiology of this disease, it is obvious thai it 
is essentially connected with pregnancy, and that there would be no 
valid ground for maintaining, as has sometimes been done, thai it may 
occur independently of conception. It is just possible, however, thai 
true entozoa may form in the substance of the uterus, which, being 
expelled per vaginam, might be taken for the results of cystic disease, 
and thus give rise to groundless suspicious as to the patient's chastity. 
Hewitt has related one case in which true hydatids, originally formed 
in the liver, had extended to the peritoneum, and were about to hurst 
through the vagina at the time of death. This occurred in an unmar- 
ried woman. One or two other examples of true hydatids forming in 
the substance of the uterus are also recorded. A very interesting ease 
is also related by Hewitt/ in which undoubted acephalocysts wore 
expelled from the uterus of a patient who ultimately recovered. A 
careful examination of the cyst and its contents would show their true 
nature, as the echinococci heads, with their characteristic booklets, 
would be discoverable by the microscope. 

It is also possible that unfounded suspicions might arise from the 
fact of a patient expelling a mass of hydatids long after impregnation. 
In the case of a widow, or woman living apart from her husband, 
serious mistakes might thus be made. This has been specially pointed 
out by McClintock, 2 who says : " Hydatids may be retained in utero 
for many months or years, or a portion only may be expelled, and the 
residue may throw out a fresh crop of vesicles, to be discharged on a 
future occasion." 

Symptoms and Progress. — The symptoms of cystic disease of the 
ovum are by no means well marked. At first there is nothing to point 
to the existence of any morbid condition, but as pregnancy advances 
its ordinary course is interfered with. There is more general dis- 
turbance of the health than there ought to be, and the reflex irritations, 
such as vomiting, may be unusually developed. The first physical sign 
remarked is rapid increase of the uterine tumor, which soon does not 
correspond in size to the supposed period of pregnancy. Thus, at the 
third month, the uterus may be found to reach up to, or beyond, the 
umbilicus. About this time there generally are more or less profuse 
watery and sanguineous discharges, which have been described as 
resembling currant juice. They no doubt depend on the breaking- 
down and expulsion of the cysts caused by painless uterine con- 
tractions. They are sometimes excessive in amount, recur with great 
frequency, and often reduce the patient extremely. Portions of cysts 
may now generally be found mingled with the discharge, and some- 
times large masses of them are expelled from time to time. Indeed, 
the discovery of portions of cysts is the only certain diagnostic sign. 
Vaginal examination, before the os has dilated, will give no informa- 
tion except the absence of ballottement. An unusual hardness or 
density of the uterus — described by Leishman, who attributes much 
importance to it, as "a peculiar doughy, boggy feeling" — has been 
pointed out by several writers. The contour of the uterine tumor, 

i Obst. Trans., 1871, vol. xii. p. 237. 

2 McClintock's Diseases of Women, p. 398. 



240 



PREGNANCY 



moreover, is often irregular. In addition, we, of course, fail to dis- 
cover the usual auscultatory signs of pregnancy. All this may aid in 
diagnosis, but nothing, except the presence of cysts in the watery bloody 
discharge, will enable us to pronounce with certainty as to the nature 
of the disease. 

Treatment. — As soon as the diagnosis is established, the indications 
for treatment are obvious. The sooner the uterus is cleared of its con- 
tents the better. Ergot may be given with advantage to favor uterine 
contraction, and the expulsion of the diseased ovum. Should this fail, 
more especially if the hemorrhage be great, the fingers, or the whole 
hand, must be introduced into the uterus, and as much as possible of 
the mass removed. The uterine cavity should then be well washed 
out with an antiseptic solution, such as creolin and water, or water 
with sufficient tincture of iodine dropped into it to give it a sherry 
color. As the os is likely to be closed, its preliminary dilatation by 
Hegar's dilators, or by a Barnes's bag, if it be already opened to some 
extent, will in most cases be required. If chloroform be then admin- 
istered, the remaining steps of the operation will be easy. On account 
of the occasional firm adhesion of the cystic mass to the uterus, too 
energetic attempts at complete separation should be avoided. Any 
severe hemorrhage after the operation can be controlled by swabbing 
out the uterine cavity with the perchloride of iron solution. 

Fig. 93. 




Myxoma fibrosum of the placenta. (After Storch.) 

Myxoma Fibrosum. — Under the name of Myxoma fibrosum (Fig. 
93) a more rare degeneration of the chorion has been described by 
Virchow and Hildebrandt, 1 characterized, not by vesicular, but fibroid 



i Monat. f. Geburt., May, 1865. 



PATHOLOGY OF THE DECIDUA AND OVUM. 241 

degeneration of* the connective tissue of the chorion. It results in the 
enlargement of the chorionic villi by fibrous hypertrophy, forming 
distinct tumors in the placental structure, and is more frequently met 
with in the later than the curlier periods of pregnancy. Jt docs not, 
therefore, necessarily lead to the death of the child. 1 

Pathology of the Placenta. — The pathology of the placenta has of 
late years attracted much attention, and it has an important practical 
bearing, in consequence of its effect on the child. 

Placentea vary considerably in shape. They may be crescentic, or 
spread over a considerable surface, in consequence of the chorion villi 
entering into communication with a larger portion of the decidua than 
usual (Placenta membranacea). Such forms, however, are merely of 
scientific interest. The only anomaly of shape of any practical im- 
portance is the formation of what have been called placental succenturice. 
These consist of one or more separate masses of placental tissue, pro- 
duced by the development of isolated patches of chorion villi. Hohl 
believes that they always form exactly at the junction of the anterior 
and posterior walls of the uterus, which in early pregnancy is a mere 
line. As the uterus expands, the portions of placenta on each side of 
this become separated from each other. They are only of consequence 
from the possibility of their remaining unnoticed in the uterus after 
delivery, and giving rise to secondary post-partum hemorrhage. The 
rare form of double placenta with a single cord, figured in the accom- 
panying woodcut (Fig. 94), was probably formed in this way, and the 
supplementary portion, in such a case, might readily escape notice. 

The placenta may also vary in dimensions. Sometimes it is of 
excessive size, generally when the child is unusually big, but not unfre- 
quently in connection with hydramnios, the child being dead and 
shrivelled. In other cases it is remarkably small, or at least appears 
to be so. If the child be healthy, this is probably of no pathological 
importance, as its smallness may be more apparent than real, depending 
on its vessels not being distended with blood. When true atrophy of 
the placenta exists, the vitality of the foetus may be seriously interfered 
with. This condition may depend either on a diseased state of the 
chorion villi, or of the decidua in which they are implanted. 2 The 
latter is the more common of the two ; and it generally consists in 
hyperplasia of the connective tissue of the decidua, which presses on 
the villi and vessels, and gives rise to general or local atrophy. The 
change is similar in its nature to that observed in cirrhosis of the liver, 
and certain forms of Bright's disease. It has been specially studied 
by Hegar and Maier, 3 who describe it as beginning with a development 
of the elongated fusiform cells of the decidua, accompanied by an 
increase of the intercellular granular material. Eventually the cells 
undergo fatty degeneration, and the Avhole structure becomes fibroid. 
This has generally been ascribed to inflammatory changes, and, under 
the name of placentitis, has been described by many authors, and has 
been considered to be a common disease. To it are attributed many 

1 Pricstlev : The Pathology of Intra-uterine Death, p. l.">(>. 

2 Whittaker : Amer. Journ. of Obstet., 1870-71. vol. iii. p. 229. 

3 Virchow's Archiv, 1671. 

16 



242 



PREGNANCY 



of the morbid alterations which are commonly observed in placenta^ 
such as hepatizations, circumscribed purulent deposits, aud adhesions 
to the uterine walls. Many modern pathologists have doubted whether 
these changes are in any proper sense inflammatory. Whittaker 
observes on this point : " The disposition to reject placentitis altogether 
increases in modern times. Indeed, it is impossible to conceive of in- 
flammation on the modern theory (Cohnheim) of that process, since 
there are no capillaries, in the maternal portion at least, through whose 
walls a ' migration ' might occur, and there are no nerves to regulate 
the contractility of the vessel-walls in the entire structure." Eobin 

Fig. 94. 




Double placenta, with single cord. 



thus explains the various pathological changes above alluded to : 
" What has been taken for inflammation of the placenta is nothing else 
than a condition of transformation of blood-clots at various periods. 
What has been regarded as pus is only fibrin in the course of dis- 
organization, and in those cases where true pus has been found the pus 
did not come from the placenta, but from an inflammation of the tissue 
of the uterine vessels and an accidental deposition in the tissue of the 
placenta." The extravasations of blood here alluded to are of very 
common occurrence, and they are found in all parts of the organ : in 
its substance, on its decidual surface, or immediately below the amnion, 
where they serve as points of origin for the cysts that are often there 
observed. The fibrin thus deposited undergoes retrograde metamor- 
phosis as in other parts of the body : it becomes decolorized, it under- 



PATHOLOGY OF THE DECIDUA AND OVUM. 



243 



goes fatty degeneration, or becomes changed into calcareous masses; 
and in this way, it is supposed, may be explained the various patho- 
logical changes which are so commonly observed. The amount of 
retrograde metamorphosis, and the precise appearance presented, will, 
of course, depend on the time that has elapsed since the blood ex- 
travasations took place. 

Fatty degeneration of the placenta, and its influence on the 
nutrition of the fetus, have been specially studied in this country by 
Barnes and Druitt. Yellowish masses of varying sizes are very com- 
monly met with in placentae, and these are found to consist, in great 
part, of molecular fat, mixed with a fine network of fibrous tissue. 

Fig. 95. 



4«M 




Fatty degeneration of the placenta. 

The true fatty degeneration, however, specially affects the chorion villi 
(Fig. 95). On microscopic examination they are found to be altered 
and misshapen in their contour, and to be loaded with fine granular 
fat-globules. Similar changes are observed in the cells of the decidua. 
The influence on the foetus will, of course, depend on the extent to 
which the functions of the villi are interfered with. The probable 
cause of this degeneration is, no doubt, some obscure alteration in 
the nutrition of the tissue, depending on the state of the mother's 
health. The probability is that generally the fatty degeneration is 
not a primitive change, but a stage of some other morbid condition 
which precedes or is associated with it. Barnes believes that syphilis 
has much influence in its production. Druitt has pointed out that 
some amount of fatty degeneration is always present in a mature 



244 



PREGNANCY. 



placenta, and is probably connected with the physiological separation 
of the organ : and Goodell has more recently suggested that an unusual 
amount of this change may be merely an anticipation of the natural 
termination of the life of the placenta. 1 

Other morbid states of the placenta, of greater rarity, are occasion- 
ally met with ; as an oedeniatous infiltration of its tissue, always occur- 
ring, according to Lange, in cases of hydramnios, pigmentary and 
calcareous dej:>osits, and tumors of various kinds; but these require 
only a passing mention. 

Pathology of the Umbilical Cord. — The umbilical cord may be 
of excessive length, varying from eighteen to twenty inches, which is 
its average measurement, up to fifty or sixty inches, and a case is re- 
corded in which it even reached the extraordinary length of nine feet. 
If unusually long it may be twisted round the limbs or neck of the 
child, and the latter position may, in exceptional instances, prove 
injurious during labor. 

Some authors refer cases of spontaneous amputation of foetal limbs 
in utero to constrictions by the umbilical cord, but this accident is 

more probably produced by filamentous 
FlG - 9( adnexa of the amnion. Knots in the cord 

are not uncommon, and they result from 
the foetus, in its movements, passing 
through a loop of the cord (Fig. 96). If 
there is an average amount of "Wharton's 
jelly in the cord the vessels are protected 
from pressure, and no bad effects follow. 
Gery, in a recent paper on the subject, 2 
attempts to show that such knots are more 
important than is generally believed, and 
relates two cases in which he believes them 
to have caused the death of the foetus. 

Extreme torsion of the cord, an exag- 
geration of the spiral twists generally ob- 
served, may prove injurious, and even fatal 
to the child by obstructing the circulation 
in the vessels. Sj^aeth mentions three cases 
in which this caused the death of the foetus, 
the cord being twisted until it was re- 
duced to the thickness of a thread. Some 
recent writers, 3 however, believe that ex- 
treme twisting of the cord is a post-mortem phenomenon following 
rotation of the foetus produced, after its death, by maternal movements. 

Anomalies in the distribution of the vessels of the cord are of 
common occurrence. The cord may be attached to the edge, instead 
of to the centre, of the placenta (battledore placenta). It may break 
up into its component parts before reaching the placenta, the vessels 
running through the membranes; and if, in such a case, traction on 
the cord be made, the separate vessels may lacerate, and the cord 




Knots of the umbilical cord. 



i Amer. Journ. of Obstet.. 1S69-70, vol. ii. p. 535. 

2 LTnion Medicale, October, 1876. 

s Schauta : Arch. f. Gyn., 1881, Bd. xix. S. 96. 



PATHOLOGY OF THE DKOIDUA AND OVUM. 245 

become detached. There may be two veins and one artery, or only 
one vein and one artery, or there may be two separate cords to one 
placenta. These and other anomalies that might be mentioned are of 
little practical importance. 

Pathology of the Amnion. — The principal pathological condition 
of the amnion with which we are acquainted is that which is associated 
with excessive secretion of liquor amnii, and is generally known under 
the name of hydramnios, which term Kidd 1 limits to cases in which 
more than two quarts of amniotic fluid exist. Its precise cause is still 
a matter of doubt. By some it is referred to inflammation of the 
amnion it-elf: at other times it is apparently connected with some 
morbid state of the decidua, which may be found diseased and hyper- 
trophied. The foetus is very often dead and shrivelled, and the 
placenta enlarged and (edematous. It does not necessarily follow, 
however, that hydramnios causes the death of the child. Out of thirtv- 
three cases McClintock found that nine children were born dead; 2 and 
of the twenty-four born alive, ten died within a few hours, the re- 
mainder survived. There does not appear to be any marked relation 
between the state of the mother's health and the occurrence of this 
disease; and it is certainly not necessarily present when the mother is 
suffering from dropsical effusions in other parts of the body. The 
theory that the disease is of purely local origin is favored by the fact 
that when hydramnios occurs in twin pregnancy one ovum onlv is 
generally affected. The probability is that most cases of hydramnios 
are of foetal origin, and are caused by some obstruction in the foetal 
circulation, mainly in the heart and liver, the latter often syphilitic. 
If the maternal placental circulation is active, and the foetal impeded, 
compensatory dropsical effusion into the sac of the amnion occurs as a 
consecpience of the mechanical obstruction, and hydramnios results. 
Its effects, as regards the mother, are chiefly mechanical. It rarely 
begins to show itself before the fifth or sixth month of pregnancy, but 
when once it has commenced it rapidly produces a feeling of discom- 
fort and enlargement, altogether beyond that which should exist at the 
period of pregnancy which has been reached. In advanced stages the 
distress produced is often very great, the enlarged uterus pressing upon 
the diaphragm, and prodnciug much embarrassment of respiration. 
Premature expulsion of the foetus very often supervenes. Four out of 
McClintock's patients died after labor, showing that the maternal 
mortality is high — a result which he refers to the debilitated state of 
the women who were the subjects of the disease. 

[Hydramnios is a true cystic dropsy of the amniotic sac, and, 
although due to different causes, is in the worst cases the result of 
obstruction in the placen to-foetal circuit of bloodvessels, and mainly 
in the liver or heart of the foetus. The amnion has the anatomical 
features of a secreting membrane, and is capable of endosnio>is and 
exo>mosis, the latter of which is notably exhibited in the removal of 
liquor amnii after foetal death in an ectopic pregnancy. When from 

* "On the Diagnosis of Dronsv of the Amnion." Proceedings of the Obstetrical Society of 
Dublin, May 11, 1-7- . 
2 Diseases of Women, j 



246 PREGNANCY. 

any cause the circulation of blood is impeded in the foetus, aud the 
placenta still keeps up its functional activity, the disparity between 
placental supply and foetal requirement will produce a dropsical 
effusion as the result of the mechanical obstruction ; hence the large 
proportion of deaths in the foetus in cases of hydramnios. — Ed.] 

Diagnosis. — The diagnosis is not, as a rule, difficult. It has to be 
distinguished from ascitic distention of the abdomen, from enlargement 
of the uterus from twin pregnancy, and from ovarian tumor, or preg- 
nancy complicated with ovarian tumor. The first will be recognized 
by the superficial position of the fluid; the difficulty of feeling the 
contour of the uterus, which is obscured by the surrounding fluid, and 
the results of percussion, which show that the fluid is free in the peri- 
toneal cavity; and by the coexistence of dropsical effusions in other 
parts of the body. The second may be difficult, and even impossible, 
to diagnose from it: generally, however, in hydramnios the uterine 
tumor is more distinctly tense or fluctuating; the foetal limbs cannot 
be felt on palpation ; and the lower segment of the uterus, as felt per 
vaginam, is unusually distended, the presenting part not being appreci- 
able. Ovarian tumors, alone or complicating pregnancy, may also be 
difficult to distinguish from dropsy of the amnion. The general history 
of the case, and the presence or absence of signs of pregnancy, may 
enable us to arrive at a diagnosis ; and Kidd points out that the posi- 
tion of the uterus, whether gravid or not, is usually low down in the 
pelvis in ovarian dropsy, while in dropsy of the amnion it is drawn 
high up, and reached with difficulty on vaginal examination. 

During labor an excessive amount of liquor amnii is often a cause 
of deficient uterine action and delay, the pains being feeble and in- 
effective. This, of course, tells chiefly in the first stage, which is often 
much prolonged, unless the membranes are punctured early, and the 
superabundant fluid is allowed to escape. 

Treatment. — Xo treatment is known to have any effect on the 
disease. If the discomfort and distention are very great, it may be 
absolutely necessary to puncture the membranes, and allow the water 
to escape. This inevitably brings on labor. If the pregnancv be not 
sufficiently advanced to give hope for the birth of a living child, we 
would not, of course, resort to this expedient unless the mother's 
health was seriously imperilled. It is possible that in such cases the 
patient might be relieved by inserting a minute aspirating needle 
through the os, and removing a certain quantity of the liquor amnii 
by aspiration, without inducing the labor. I have never had an oppor- 
tunity of trying this expedient, but it seems a possibility. 

Deficiency of Liquor Amnii. — A defective amount of liquor 
amnii is said to favor certain malformations, by allowing the uterus to 
compress the foetus unduly. It certainly occasionally gives rise to 
adhesion between the foetus and the membranes, and to the formation 
of amniotic bands which are capable of producing certain foetal de- 
formities (pp. 245, 250). 

The liquor amnii itself varies much in appearance. It is sometimes 
thick and treacly, instead of limpid, and it may be offensive in odor. 
The cause of these variations is not well understood. 



I' A THOLO Q Y OF THE 1) B C 1 D A A ND V V M . 247 

Pathology of the Foetus. — There is abundant evidence thai the 
foetus in utero is Bubject to many diseases, some of which cause its 

death, and ethers leave distinct traces of their existence, although not 
proving fatal. The Bubject is of great importance, and is well worthy 
of study. There is still much to be done in this direction, which may 
lead to important practical results. I can, however, do little more 
than enumerate some of the principal affections which have been 
observed. 

Diseases Transmitted through the Mother. — It is a well-estab- 
lished feet that the various eruptive fevers from which the mother may 
suffer may be communicated to the fcetus in utero. When the mother 
is attacked with confluent smallpox she almost always aborts, but not 
necessarily so when it is discrete or modified. In such cases it has 
often happened that the foetus has been born with evident marks of 
smallpox. Cases are on record which prove that the foetus was 
attacked subsequently to the mother. Thus a mother attacked with 
smallpox has miscarried, aud has given birth to a living child showing 
no trace of the disease, which, however, showed itself in two or three 
days; proving that it had been contracted, and had run through its 
usual period of incubation, -when the foetus was still in utero. It does 
not follow, however, that the foetus is affected, as Serres has collected 
twenty-two cases in which women suffering from smallpox gave birth 
to children who had not contracted the disease. It has been supposed 
that in such cases the child is protected from smallpox, though it has 
shown no symptom of having had the disease. Tarnier, however, 
cites two instances in which such children had smallpox two years 
after birth. Madge and Simpson record cases in which vaccination 
performed on the mother during pregnancy protected the foetus, on 
whom all subsequent attempts at vaccination failed. There is evidence 
also to prove that the disease may be transmitted to the foetus through 
a mother who is herself unsusceptible of contagion; the child having 
been covered with smallpox eruption, the mother being quite free from 
it. It is probable that the same facts which have been observed with 
regard to smallpox hold true with reference to other zymotic diseases, 
such as scarlet fever and measles, although there is not sufficient 
evidence to justify a positive assertion to that effect. 

Amongst other maternal diseases, malaria and lead-poisoning arc 
known to affect the foetus in utero. Dr. Stokes relates cases in which 
the mother suffered from tertian ague, the child having also attacks, as 
evidenced by its convulsive movements, appreciable by the mother, 
which took place at the regular intervals, but at a different time from 
the mother's paroxysms. In other cases the febrile paroxysm comes 
on at the same time in the foetus as in the mother; and the fact lias 
been verified by the observation that the paroxysms continued to recur 
simultaneously after delivery. The foetus has also been born with dis- 
tinct malarious enlargement of the spleen. From the frequency with 
which largely hypertrophied spleens are seen in mere infants in 
malarious districts, I imagine that the intra-uterine disease must be 
common. I have frequently observed this fact in India, although, of 
course, without any possibility of ascertaining if the mothers had 



248 PREGNANCY. 

suffered from intermittent fever during pregnancy. Lead-poisoning is 
also known to have a most prejudicial effect on the foetus, and fre- 
quently to lead to abortion. M. Paul has collected eighty-one cases 1 
in which it caused the death of the foetus, in some not until after birth; 
and occasionally it seems to have affected the foetus even when the 
mother escaped. 

Of all blood-dyscrasise transmitted to the foetus, the most important 
is syphilis. Its influence in producing repeated abortion is elsewhere 
described (p. 257). It may unquestionably be transmitted to the foetus 
without producing abortion, and at term the mother may be either 
delivered of a living child, bearing evident traces of the disease ; of a 
dead child similarly affected; or of an apparently healthy child in 
whom the disease develops after a lapse of a month or two. These 
varying effects probably depend on the intensity of the poison ; and 
the longer the time that has elapsed since the origin of the disease 
in the affected parent, the better will be the chance for the child. The 
disease is, no doubt, generally transmitted through the mother, and if 
she be affected at the time of conception, the infection of the foetus 
seems certain. If, however, she contracts the disease at an advanced 
period of pregnancy, the child may entirely escape. Bicord even 
believes that syphilis contracted after the sixth month of pregnancy 
never affects the child. The father alone may transmit the disease to 
the ovum; and Hutchinson has recorded cases to show that the mother 
may become secondarily affected through the diseased foetus. The 
evidences of syphilitic taint in a living or dead child are sufficiently 
characteristic. The child is generally puny and ill-developed. An 
eruption of pemphigus is common, either fully-developed bullae, or 
their early stage, when they form circular copper-colored patches. 
This eruption is always most marked on the hands and feet, and a 
child born with such an eruption may be certainly considered syphi- 
litic. On post-mortem examination the most usual signs are small 
patches of suppuration in the* thymus, similar localized suppurations 
in the tissues of the lungs, indurated yellowish patches in the liver, 
and peritonitis, the importance of which in causing the death of syphi- 
litic children has been specially dwelt on by Simpson. 2 

The most important of the inflammatory diseases affecting the foetus 
is peritonitis. Simpson has shoAvn that traces of it are very frequently 
met with, and that it is not always syphilitic. Sometimes it has been 
observed when the mother has been in bad health during pregnancy, 
and at others it seems to have resulted from some morbid condition 
of the foetal viscera. Pleurisy with effusion is another inflammatory 
affection which has been noticed. 

The dropsical affections most generally met with are ascites and 
hydrocephalus, which may both have the effect of impeding delivery. 
Of these, hydrocephalus is the more common, and may give rise to 
much difficulty in labor. Its causes are uncertain, but it probably 
depends on some altered state of the mother's health, as it is apt to 
recur in several successive pregnancies, and is not infrequently asso- 

i Arch. gen. de Med., 1860. 2 Obst. Works, vol. i. p. 117. 



PATHOLOGY OF THE DECIDLA A X D OVUM. 249 

ciatcd with an imperfectly developed vertebral column and spina bifida. 
The fluid collects in the ventricles, which it greatly distends, and these 
then produce expansion and thinning of the cranium, the bones of 
which are widely separated from each other at the sutures, which are 
prominent and fluctuating. In a few cases internal hydrocephalus 
may he complicated, and the diagnosis in labor consequently obscured 
by the coexistence of what has been called "external hydrocephalus." 
This consists of a collection of fluid between the skull and the scalp, 
which may be either formed there originally or may collect from a 
rupture of one of the sutures or fontanelles during labor, through 
which the intra-cranial fluid escapes. 

Ascites is generally associated with hydramnios, and sometimes with 
hydrothorax, or other dropsical effusions. It is a rare affection, and 
according to Depaul 1 extreme distention of the bladder is not un- 
frequently mistaken for it. 

Tumors of different kinds may be met with in various parts of the 
child's body, which sometimes grow to a great size and impede delivery. 
Tarnier records cases of meningocele larger than a child's head, and 
large cvstic growths have been observed attached to the nates, pectoral 
region, or other parts of the body. Cancerous tumors of considerable 
size, either external or of the viscera, have also been met with. Other 
foetal tumors may be produced by congenital deformities, such as pro- 
jection of the liver or other abdominal viscera through a deficiency of 
the abdominal wall; or spina bifida from imperfectly developed verte- 
bra?. The amount of dystocia produced by such causes will, of course, 
vary much in proportion to the size, consistency, and accessibility of 
the tumor. 

Wounds and Injuries of the Foetus. — Accidents of serious gravity 
to the foetus may happen from violence to which the mother has been 
subjected, such as falls or blows, without necessarily interfering with 
gestation. Many curious examples of this kind are on record. Thus 
a child has been born presenting a severe lacerated wound extending 
the whole length of the spine, where both the skin and the muscles 
had been torn, and which seems to have resulted from the mother 
having fallen in the last month of pregnancy. Similar lacerations and 
contusions have been observed in other parts of the body, the wounds 
being in various stages of cicatrization, corresponding to the lapse of 
time since the accident had occurred. Intra-uterine fractures are not 
rare, apparently arising from similar causes. In some of these cases 
the broken ends of the bones had united, but, from want of accurate 
apposition, at an acute angle, so as to give rise to much subsequent 
deformity. Chaussier records two cases in which there were many 
fractures in the same child — in one, one hundred and thirteen, and in 
another forty-two — which were in different stages of repair. He 
attributes this curious occurrence to some congenital defect in the 
nutrition of the bones, possibly allied to mollities ossium. 2 

Intra-uterine amputations of foetal limbs have not unfrequcntly been 
observed. Children are occasionally born with one extremity more or 

1 Tanner's Cazeaux, p. 855. 2 Gazette hebdom., 1860. 



'250 



PREGNANCY. 



Fig. 97. 




Intra-uterine amputation of both 
arms and legs. 



less completely absent, and cases are known in which the whole four 
extremities were wanting (Fig. 97). The mode in which these mal- 
formations are produced has given rise to 
much discussion. At one time it was sup- 
posed that the deficiency of the limb was due 
to gangrene of the extremity, and subsequent 
separation of the sphacelated parts. Reuss, 
who has studied the whole subject very 
minutely/ considers gangrene in the unrup- 
tured ovum to be an impossibility, for that 
change cannot occur unless there is access of 
air, and when portions of the separated 
extremity are found in utero, as is often the 
case, they show evidences of maceration, but 
not of decomposition. The general belief is 
that these intra-uterine amputations depend 
on constriction of the limb by folds or bands 
of the amnion — most often met with when, 
the liquor amnii is deficient in quantity — 
which obstruct the circulation, and thus give 
rise to atrophy of the part below the constric- 
tion. It has been supposed that the umbilical 
cord might, by encircling the limb, produce a like result. It appears 
doubtful, however, whether this cause is sufficient to produce complete 
separation of the limb, as any great amount of constriction would 
interfere with the circulation through the cord. Sometimes, when 
intra-uterine amputation occurs, the separated portion of the limb is 
found lying loose in the amniotic cavity, and is expelled after the 
child. Cases of this kind have been recorded by Martin, Chaussier, 
and Watkinson. More often no trace of the separated extremity can 
be found. The explanation probably depends upon the period of utero- 
gestation at Avhich amputation took place. If it occurred at a very 
early period of pregnancy, before the third month, the detached portion 
would be minute and soft, and would easily disappear by solution. If 
at a later period, this could hardly happen, and the detached portion 
would remain in utero. In cases of the latter kind cicatrization of the 
stump has often been observed to be incomplete. Simpson pointed out 
the occasional existence of rudimentary fingers or toes on the stump of 
an amputated limb, such as are seen on the thighs in Fig. 97. These 
he attributed to an abortive reproduction of the separated extremity, 
analogous to what is observed in some of the lower animals. This 
explanation has been contested with much show of reason. Martin 
believes that the reproduction is only apparent, and that the rudi- 
mentary extremities are, in reality, instances of arrested development. 
The constricting agents interfered with the circulation sufficiently to 
arrest the growth of the limb below the site of constriction, but not 
sufficiently to effect complete separation. If constriction occurred at a 
very early stage of development, an appearance similar to that observed 



i Scanzoni's Beitrage, 1869. 



PATHOLOGY OF THE DECIDUA AND OVUM. 251 

by Simpson would be produced. It does not follow, however, thai all 
cases of absence of limbs depend on intra-uterine amputations. In 
some cases they Mould appear to be the result of a spontaneous arrest 
of development, or of congenital monstrosity. Mr. Scott ' relate- a 

case in which a distinct hereditary tendency Mas evident, and here the 
deformity certainly could not have resulted from the constriction of 
amniotic bands. In this family the grandfather had both forearms 
wanting, with rudimentary fingers attached ; the next generation 
escaped ; but the grandchild had a deformity precisely similar to that 
of the grandfather. 

[Arrested Pullulation. — The absence of a hand where there are 
rudimentary evidences of an attempt to form the thumb and fingers 
can be accounted for much more satisfactorily on the theory of an 
arrested development taking place in the latter half of the second 
month of embryonic life than upon the hypothetical idea that there 
has been first an amputation in utero, and then an attempt of Nature to 
reproduce the lost digits by a new budding process, as taught by 
Simpson and Annandale. More than thirty years ago I became fully 
satisfied that there Mas an inclination in Nature to repeat itself so 
exactly during the pullulative period of embryonic growth that eases of 
congenital deficiency of the thumb and fingers of a precisely similar 
character must from time to time present themselves to the eye of the 
medical observer. It so happened that three such typical cases, all 
exactly alike, in two boys and one girl, each being strangely without 
the left hand, came under my notice during a short period of years. 
The forearm in each ended in a well-rounded and slightly-flattened 
stump, from which protruded a row of pisiform nail-less bodies repre- 
senting the embryonic commencement of the formation of a thumb 
and four fingers. I saw these subjects at different ages of infancy and 
childhood, and the little pea-like bodies remained the same, with the 
exception that they became slightly larger. In a fourth case, a boy, 
the finger rudiments were entirely absent, and there Mas an attempt to 
form a thumb, which was useless and about three-quarters of an inch 
long. The boy developed into a powerful man of six feet. Cases of 
the precise type of the three first named have come under the observa- 
tion of medical friends. — Ed.] 

Death of Foetus. — When from any cause the foetus has died during 
pregnancy, it may be either soon expelled, or it may be retained in utero 
for a longer or shorter time, or even to the full period. The changes 
observed in such foetuses vary considerably according to the age of the 
foetus at the time of death, or the time that it has been retained in 
utero. If it die at an early period, when the tissues are very soft, it 
may entirely dissolve in the liquor amnii, and no trace of it may be 
found when the membranes are expelled. Or it may shrivel or mum- 
mify; and if this happen in a twin pregnancy, as sometimes occurs, 
the growing foetus may compress and flatten the dead one against the 
uterine wall. 

At a later period of pregnancy a dead fetus undergoes changes 

1 Obst. Trans., 1872, vol. xiii. p. 91. 



252 PREGNANCY. 

ascribed to putrefaction, but which produce appearances different from 
those of decomposition in animal textures exposed to the atmosphere. 
There is no offensive smell, as in ordinary decay. The tissues are all 
softened and flaccid. The more manifest changes are in the skin, the 
epidermis of which is separated from the cutis vera, which has a deep 
reddish color. This is especially apparent on the abdomen, which is 
flaccid, and hollow in the centre. The internal organs are much 
altered. The brain is diffluent and pulpy, and the cranial bones loose 
within the scalp. The structures of the muscles and viscera are in 
various stages of transformation, many having undergone fatty changes, 
and contain crystals of margarin and cholesterin. The extent to which 
these changes occur depends, in a great measure, on the length of time 
the foetus has been dead, but they do not admit of our estimating with 
any degree of accuracy what that time has been. 

The symptoms and diagnosis of the death of the foetus may here 
be considered. They are, unfortunately, not very reliable. The cessa- 
tion of the foetal movements cannot be depended on, as they are 
frequently unfelt for days or weeks, when the child is alive and well. 
Sometimes the death of the foetus is preceded by its irregular and 
tumultuous movements, and, in women who have been delivered of 
several dead children in succession, this sensation may guide us in our 
diagnosis. This suspicion may be confirmed by auscultation. The 
mere fact that we are unable, at any given time, to hear the foetal heart 
will not justify an opinion that the foetus is dead. If, however, the 
foetal heart has been distinctly heard, and after one or two careful 
examinations, repeated at separate times, it cannot again be made out, 
the probability of the child being dead may be assumed. Certain 
changes in the mother's health have been noted in connection with 
the death of the foetus, such as depression and lowness of spirits, a 
feeling of coldness and weight about the lower parts of the abdomen, 
paleness of the face, a livid circle round the eyes, irregular shiverings 
and feverishness, shrinking of the breasts, and diminution in the size 
of the abdominal tumor. All these, however, are too indefinite to 
justify a positive diagnosis, and they are not infrequently altogether 
absent. At most they can do no more than cause a suspicion as to 
what has happened. 



CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and Frequency of Abortion. — The premature ex- 
pulsion of the foetus is an event of great frequency. The number of 
foetal lives thus lost is enormous. There are few multipara who have 
not aborted at one time or other of their lives. Hegar estimates that 



ABORTION AND PREMATURE LABOR. 253 

about one abortion occurs to every eighl or ten deliveries at term. 
Whitehead lias calculated that at least 90 per cent, of married women 
who lived to the change of life had aborted. The influence of this 
incident on the future health of the mother is also of great importance. 
It rarely, indeed, proves directly fatal, but it often produces great 
debility from the profuse loss of blood accompanying it ; and it, is one 
of the most prolific causes of uterine disease in after-life, possibly 
because women are apt to be more careless during convalescence than 
after delivery, and the proper involution of the uterus is thus more 
frequently interfered with. 

Definition. — A not uncommon division of the subject is into abortion, 
miscarriage, and premature labor, the first name being applied to expul- 
sion of the ovum before the end of the fourth month of utero-gestation ; 
miscarriage, to expulsion from the end of the fourth to the end of the 
sixth month ; and premature labor, to expulsion from the end of the 
sixth month to the term of pregnancy. This is, however, a needless 
and confusing subdivision, which leads to no practical result. It 
suffices to apply the term abortion or miscarriage indiscriminately to 
all cases in which pregnancy is terminated before the foetus has arrived 
at a viable age, and premature labor to those in which there is a possi- 
bility of its survival. There is little or no hope of a foetus living 
before the twenty-eighth week or seventh lunar month, and this period 
is therefore generally fixed on as the limit between premature labor and 
abortion. The rule is, however, not without an occasional, although 
very rare, exception. Dr. Keiller, of Edinburgh, has recorded an 
instance in which a foetus was born alive at the fourth month, nine 
days after the mother had experienced the sensation of quickening. I 
myself recently attended a lady who miscarried in the fifth month of 
pregnancy, the child being born alive, and living for three hours. 
Several cases are on record in which after delivery in the sixth month 
the child survived and was reared. The possibility of the birth of a 
living child under such circumstances should be recognized, as it may 
give rise to legal questions of importance ; but the exceptions to the 
ordinary rule are so rare that they need not interfere with the division 
of the subject usually made. 

Abortion is Most Common in Multiparse. — Multiparas abort far 
more frequently than primiparas. This is contrary to the statement in 
many obstetrical works. Thus, Tyler Smith says, " there seems to be 
a greater danger of this accident in the first pregnancy." Schroeder, 1 
however, states that twenty-three multiparas abort to three primiparae ; 
and Dr. Whitehead, of Manchester, who has particularly studied the 
subject, believes that abortion is more apt to occur after the third and 
fourth pregnancies, especially when these take place toward the time 
for the cessation of menstruation. 

There can be no doubt that women who have aborted more than once 
are peculiarly liable to a recurrence of the accident. This can generally 
be traced to the existence of some predisposing cause which persists 
through several pregnancies, as, for example, a syphilitic taint, a 

1 Schroeder : Manual of Midwifery, p. 149. 



254 PREGNANCY. 

uterine flexion, or a morbid state of the lining membrane of the uterus. 
It is probable that in many women a recurrence of the accident induces 
a habit of abortion, or perhaps it might be more accurate to say, a 
peculiar irritable condition of the uterus, which renders the continuance 
of pregnancy a matter of difficulty, independently of any recognizable 
organic cause. 

The frequency of abortion varies much at different periods of preg- 
nancy ; and it occurs much more often in the early months, because of 
the comparatively slight connection then existing between the chorion 
and the decidua. At a very early period of pregnancy the ovum is 
cast off with such facility, and is of such minute size, that the fact of 
abortion having occurred passes unrecognized. Very many cases, in 
which the patient goes one or two weeks over her time, and then has 
what is supposed to be merely a more than usually profuse period, are 
probably instances of such early miscarriages. "Velpeau detected an 
ovum, of about fourteen days, which was not larger than an ordinary 
pea, and it is easy to understand how so small a body should pass 
unnoticed in the blood which escapes along with it. 

Up to the end of the third month, when miscarriage occurs, the ovum 
is generally cast off en masse, the decidua subsequently coming away in 
shreds or as an entire membrane. The abortion is then comparatively 
easy. From the third to the sixth month, after the placenta is formed, 
the amnion is, as a rule, first ruptured by the uterine contractions, and 
the foetus is expelled by itself. The placenta and membranes may then be 
shed as in ordinary labor. It often happens, however, that on account of 
the firmness of the placental adhesion at this period the secundines are 
retained for a greater or less length of time. This subjects the patient 
to many risks, especially to those of profuse hemorrhage, and of septi- 
caemia. For this reason, premature termination of the pregnancy is 
attended by much greater danger to the mother between the third and 
sixth months than at an earlier or later date. After the sixth month 
the course of events is not different from that attending ordinary labor. 
The prognosis to the child is more unfavorable in proportion to the 
distance from the full period of gestation at which premature labor 
takes place. 

Causes. — The causes of abortion may conveniently be subdivided 
into ike predisposing and exciting, the latter being often slight, and such 
as would have no effect in inducing uterine contractions in women 
unless associated with one or more of the former class of causes. The 
predisposition to abortion may depend on some condition interfering 
with the vitality of the ovum, or its relation to the maternal structures, 
or on certain conditions directly affecting the mother's health. 

One of the most common antecedents of abortion is the death of the 
foetus, which leads to secondary changes, and ultimately produces the 
uterine contractions which end in its expulsion. The precise causes of 
death in any given case cannot always be accurately ascertained, as 
they sometimes depend on conditions which are traceable to the 
maternal structures, at others to the ovular, or, it may be, to a combina- 
tion of the two. ,Xor does it by any means follow that the death of the 
ovum immediately results in its expulsion. The mode in which death 



ABORTION AND PREMATURE LABOR 






of tin 1 ovum produces abortion la not difficult to understand, for it 
necessarily leads to changes in the relations between the ovular and 
maternal structures ; these changes cause hemorrhages — partly external 
and partly into the membranes — which, in their turn, excite uterine 
contraction. Extravasations of blood may take place in various posi- 
tions. One of the most common is into the decidual cavity, between 
the decidua vera and the decidua reflexa, or between the decidua vera 
and the uterine walls. If the hemorrhage is only slight, and especially 
it it comes from that portion of the decidua near the internal os, and 
at a distance from the ovum, there need be no material separation, and 
pregnancy may continue. This explains the cases occasionally met 
with in which there is more or less hemorrhage, without subsequent 
abortion. When the amount of extravasated blood is at all great, 

Fig. 9S. 




An apoplectic ovum, with blood effused in masses under the fcetal surface 
of the membranes. 



separation and abortion necessarily result, and the decidua will be 
found on expulsion to have coagula on its surface, and between its 
various layers which are found to project into the cavity of the amnion 
(Fig. 98). In other cases hemorrhage is still more extensive, and, after 
breaking through the decidua reflexa, it forms clots between it and the 
chorion, and even in the cavity of the amnion. Supposing expulsion 
to take place shortly after coagula are deposited among the membranes, 
the blood is little altered, and we have an ordinary abortion. If, how- 
ever, the ovum is retained, the coagulated fibrin and the placenta or 
membranes undergo secondary changes which lead to the formation of 
moles. The so-called fleshy mole (Fig. 99) is often retained for many 
weeks or months after the death of the foetus, and during this time 
there may be but little modification of the usual symptoms of preg- 



2b6 



PREGNANCY. 



nancy ; or, as is frequently the case, it gives rise to occasional hemor- 
rhage, until at last uterine contractions come on, and it is cast off in 
the form of a thick fleshy mass having but little resemblance to the 
ordinary products of conception. The most probable explanation of 
its formation is that when hemorrhage originally took place the 
effusion of blood was not sufficient to effect the entire separation and 
expulsion of the ovum. Part of the membranes or of the placenta — 
if that organ had commenced to form — retained its organic connection 
with the uterus, wiiile the foetus perished. The attached portion of 
the placenta or membranes continues to be nourished, although abnor- 
mally. The foetus generally entirely disappears, especially if it has 
perished at an early period of utero-gestation, when it becomes dissolved 
in the liquor amnii ; or it may become macerated, shrivelled, and 




Blighted ovum, with fleshy degeneration of the membranes. 



greatly altered in appearance. The effused blood becomes decolorized 
from the absorption of the corpuscles ; and, according to Scanzoni, 
fresh vessels are developed in the fibrin, which increase the vascular 
attachment of the mole to the uterine walls. The placenta and mem- 
branes may go on increasing in thickness until they form a mass of 
considerable size. Careful microscopic examination will almost always 
enable us to discover the villi of the chorion, altered in appearance, often 
loaded with granular fattv molecules, but sufficiently distinct to be 
readily recognizable. 

Important as are the causes of abortion arising from some morbid 
condition of the ovum, they are not more so than those which depend 
on the maternal state ; and it is to be observed that the former are often 
indirect causes produced by primary maternal changes. Many of these 
maternal causes act by producing hypersemia of the uterus, which leads 
to extravasation of blood. Thus abortion is ant to occur in women who 



ABORTION AND PREMATUBE LABOR. 257 

lead unhealthy lives, such as those who occupy overheated and ill- 

ventilated room-, or indulge to excess in the fatigues and pleasures of 
society, hi the use of alcoholic drinks, and the like. Over-frequent 

coitus lias been, tor the same reason, observed to produce a remarkable 
tendency to abortion, and Parent-Duchatelet lias noted that it is of 
very frequent occurrence amongsl women of loose life. Many diseases 
Strongly predispose to it, such as levers, zymotic diseases of all kinds, 
measles, scarlel fever, smallpox, and diseases of the respiratory organs, 
such as bronchitis and pneumonia. Syphilis is well known to he one 
of the most frequent causes, and one that is likely to act in successive 
pregnancies. It may act so that the pregnancy is brought to a pre- 
mature termination, time after time, until the constitutional disease is 
eradicated by appropriate treatment. It acts in some cases through 
the influence of the father in producing a diseased ovum ; and it is the 
only cause which can with certainty be traced to the state of the father's 
health. Many other morbid conditions of the blood also dispose to 
abortion. It has been observed to be a frequent result of lead-poisoning, 
also of the presence of noxious gases in the atmosphere, such as an 
excess of carbonic acid. 

Many causes act through the nervous system, such as fright, anxiety, 
sudden shock, and the like. Thus there are numerous instances on 
record in which Avomen aborted suddenly after the receipt of some bad 
news, and it is said to have been of frequent occurrence in women im- 
mediately before execution. The influence of irritation propagated 
through the nervous system from a distance, tending to produce uterine 
contraction and abortion through the agency of reflex action, has been 
specially dwelt upon by Tyler Smith. Thus he points out that abortion 
not unfrequently occurs from the irritation of constant suckling in 
women who become pregnant during lactation. The effect of suckling 
in producing uterine contraction is, indeed, well known, and the appli- 
cation of the child to the breast for this purpose has long been recog- 
nized as a method of treatment in post-partum hemorrhage. The 
irritation of the trifacial in severe toothache ; of the renal nerves in 
cases of gravel, in albuminuria, etc. ; of the intestinal nerves in exces- 
sive vomiting, in diarrhoea, obstinate constipation, ascarides, etc., all 
act in the same way. AVe may, perhaps, also explain by this hypoth- 
esis the fact that women are more apt to abort at what would have 
been the menstrual epoch than at other times, as the ovarian nerves 
may then be subject to undue excitement. It is probable, however, 

that there may be also at these times more or less active congestion of 

. * . . . . 

the decidua, which may predispose to laceration of its capillaries and 

blood extravasation. Such congestion exists in those exceptional cases 
in which menstruation continues for one or more periods after concep- 
tion, the blood probably escaping from the space between the decidua 
vera and reflexa ; and, therefore, there is no reason to question its also 
happening even when such abnormal menstruation is not present. 

Certain physical causes may produce abortion by separating the 
ovum. Thus it may follow a fall, a blow, or other accidents of a 
trivial character. On the other hand, women may be subjected to 
injuries of the severest kind without aborting. The probability, there- 

17 



258 PREGNANCY. 

fore, is that these apparently trivial causes only operate in women who, 
for some other reason, are predisposed to the accident. This is borne 
out by the fact — which is well known in these days, when the artificial 
production of abortion is, unhappily, far from a very rare event — that 
it is by no means easy to destroy the vitality of the foetus. I myself 
know of a case in which the uterine sound was passed several times 
into a pregnant uterus without producing abortion, the pregnancy pro- 
ceeding to term. Oldham has related a similar case in which he in 
vain attempted to induce abortion by the sound in a case of contracted 
pelvis ; and Duncan has mentioned an instance in which an intra- 
uterine stem pessary was unwittingly introduced and worn for some 
time by a pregnant woman without any bad effect. The fact that 
pregnancy is with difficulty interfered Avith when there is a healthy 
relation between the ovum and the uterus, no doubt explains the 
disastrous effects of criminal abortion, which have been especially 
insisted on by many of our American brethren. 

Morbid states of the uterus have an important influence in the pro- 
duction of abortion. Any condition which mechanically interferes 
with the proper development of the uterus is apt to operate in this 
way. Amongst these may be mentioned fibroid tumors ; the presence 
of old peritoneal adhesions, rendering the womb a more or less fixed 
organ ; but, above all, flexion and displacement of the uterus. Retro- 
flexion of the uterus is, unquestionably, one of the most frequent 
factors in its production, not only on account of the irritation which 
the abnormal position sets up, but from interference with the uterine 
circulation, which leads to the effusion of blood and the death of the 
ovum. An inflamed condition of the cervical and uterine mucous 
membranes will act in the same way should pregnancy have occurred, 
although such a condition more often prevents conception taking place. 

Symptoms. — One of the earliest indications of impending abortion is 
more or less hemorrhage. This may at first be slight, and may last for a 
short time only, recurring after an interval of time, or it may commence 
with a sudden and profuse discharge. Occasionally it is very abundant, 
and its continuance and amount form one of the gravest symptoms of 
the accident. After the loss of blood has continued for a greater or 
less length of time — it may be even for some days — uterine contrac- 
tions come on, recurring at regular intervals, and eventually lead to 
the expulsion of the ovum. More rarely the impending miscarriage 
commences with pains, which lead to laceration of vessels and hemor- 
rhage. 

As long as one or other of these symptoms exist alone, we may 
hope to avert the threatened miscarriage ; but when both occur together 
there is little or no chance of its being arrested. Certain premonitory 
symptoms are described by authors as common in abortion, such as 
feverishness, shivering, a sensation of coldness ; all of which are 
obscure and unreliable, and are certainly much more frequently absent 
than present. 

If the pregnancy be early it is probable that the entire ovum will 
be shed with little trouble, and it often passes unperceived in the clots 
which surround it. It is, therefore, of importance that all the dis- 



A110RTION AND PBEMAT1 RE LABOR. 259 

charges should be very carefully examined. After the second month 
the rigid and undilated cervix presents a formidable obstacle to the 
escape of the ovum, and it may be a considerable time before there is 
sufficient dilatation to admit of its passage. Tins is gradually effected 
by the continuance of pains, but not without a severe Joss of blood. 
It may be that the amnion is ruptured and the foetus expelled first. 
After a lapse of time the seeundines arc also shed, but there may be a 
considerable delay, amounting even to days, before this is effected. 
As long as any portions of the membranes arc retained in utero, the 
patient is necessarily subjected to considerable risk, not only from the 
continuance of hemorrhage, but also from septicaemia. Hence it may 
be laid down as a rule that we can never consider our patient out of 
danger until we have satisfied ourselves that the whole of the uterine 
contents have been expelled. 

Treatment. — Our first endeavor in any ease of impending miscar- 
riage will be, of course, to avert the threatened accident. If hemor- 
rhage has not been excessive, and if, on vaginal examination — which 
should always be practised — we find no dilatation of the os, we may 
entertain a reasonable hope of success. If, on the contrary, we find 
the os beginning to open, if we are able to insert the finger through it 
so as to touch the ovum, especially if pains also exist, we are justified 
in considering abortion to be inevitable, and the indication will then 
be to have the ovum expelled, and the case terminated as soon as pos- 
sible. In the former case the most absolute rest is the first thins: to 
insist on. The patient should be placed in bed, not overburdened. 
with clothes, in a cool temperature, and she should have a light and 
easily assimilated diet. All movements, even rising out of bed to 
empty the bladder or bowels, should be absolutely prohibited. To 
avert the tendency to the commencement of uterine contraction there 
is no remedy so useful as opium, which must be given freely and fre- 
quently repeated. It may be administered either iii the form of 
laudanum or of Battlcy's sedative solution, which has the advantage 
of producing less general disturbance. It may be advantageously 
exhibited in doses of from twenty to thirty minims, and repeated after 
a few hours. A still better preparation is ehlorodyne, which I have 
found of extreme value in arresting impending miscarriage, in doses of 
teu minims, repeated every third or fourth hour. If from any other 
cause it is considered inadvisable to give the sedative by the mouth, 
it may be administered in a small starch enema per rectum. In all 
cases it will be necessary to keep the patient more or less under the 
influence of the drug for several days, and until all symptoms of mis- 
carriage have passed away. Care should be taken that the bowels do 
not become locked up by the action of the opiates — as this might of 
itself be a cause of irritation — and their constipating effects ought to 
be obviated by small doses of castor oil, or other gentle aperient. 
Various subsidiary methods of treatment have been recommended, such 
as bleeding from the arm, or the local application of leeches in sup- 
posed plethoric states of the system ; revulsives, such as dry cupping to 
the loins ; the application of ice, to check hemorrhage ; astringents, such 
as acetate of lead or gallic acid, for the same purpose. Most of these, 



260 PREGNANCY. 

if not hurtful, will be at least useless. The cases in which venesection 
would be beneficial are extremely rare, and the local applications, espe- 
cially cold, are much more apt to favor than to prevent uterine action. 

In cases of repeated miscarriage in successive pregnancies, a special 
course of prophylactic treatment is indicated, and is often attended 
with much success. In cases of this kind the first indication, and one 
which ought to be carefully attended to, is to seek for, and, if possible, 
to remove or mitigate the cause which has given rise to the former 
abortions. Those causes which depend on constitutional states must 
first be carefully investigated, and treated according to the indications 
present. These may be obscure and not easily discovered ; but it is 
certainly unwise to assume too readily the existence of what has been 
called " a habit of abortion," which further inquiry may prove to be 
only an indication of constitutional debility, degeneracy of the placental 
structures, or a latent and unsuspected syphilitic taint. If constitu- 
tional debility be present to a marked extent, a generous diet and a 
restorative course of treatment (preparations of iron, quinine, and other 
suitable tonics) may effect the desired object. 

Local congestion of the uterus or a general plethoric state of the 
patient have often been supposed to be efficient causes of recurring 
abortion. Dr. Henry Bennet has especially dwelt on the influence of 
congestion and abrasions of the cervix in causing premature expulsion 
of the foetus, 1 and recommends the topical application of nitrate of 
silver or other caustics to the inflammatory abrasions existing on the 
neck of the womb. Formerly venesection was a favorite remedy ; and 
many authors have recommended the local abstraction of blood by 
leeches applied to the groin, or around the anus, or even to the cervix. 
The influence of general plethora is more than doubtful ; and although 
local congestions are, probably, much more effective causes, still it would 
seem more judicious to treat them by rest and local sedatives rather 
than by topical applications, which, injudiciously applied, might pro- 
duce the very accident they were intended to prevent. 

The position of the uterus should be carefully investigated. If it 
be found to be retroflexed, a well-fitting Hodge's pessary should be 
applied, so as to support it until it has completely risen out of the 
pelvis. 

The possibility of syphilitic infection should always be inquired 
into, for this poison may act on the product of conception long after 
all appreciable traces of it have disappeared from the infected parent. 
Should there be recurrent abortions in a patient Avho had formerly 
suffered from syphilis, or whose husband had at any time contracted 
the disease, no time should be lost in using appropriate anti-syphilitic 
remedies, which should invariably be administered both to the husband 
and wife. Diday especially insists that in such cases it is not sufficient 
to submit the father and mother to a mercurial course in the absence 
of pregnancy, but that, as each successive impregnation occurs, the 
mother should again commence anti-syphilitic treatment, even though 
she has no visible traces of the disease. 2 In this way there is reason- 

1 On Inflammation of the Uterus, p. 432. 

2 Diday, Infantile Syphilis, Sjd. Soc. Trans., p. 207. 



ABORTION AND PREMATURE LABOR. 261 

able ground for hoping that infection of the ovum may be prevented. 
1 think, too, that we may Ik 1 the more encouraged to persevere in the 

treatment o\' these unfortunate eases, from the tact that the syphilitic 
poison tends to wear itself out. I have seen several cases in which 
this taint at first produced early abortion, then each successive preg- 
nancy was <>f longer duration, until eventually a living child was horn. 

In fatty degeneration of the chorion villi, and in other morbid states 
of the placenta, which act by preventing the proper nutrition of the 
foetus and the due aeration of its blood, there is no reliable mean- of 
treatment except the general improvement of the mother's health. 
Simpson strongly recommended the administration of chlorate of potash 
in cases in which the child habitually dies in the later months of preg- 
nancy, on the supposition that it supplied to the blood a large amount 
of oxygen, and thus made up for any deficiency in the supply of that 
element through the placental tufts. The theory is, at best, a doubtful 
one, although I believe the drug to be unquestionably beneficial in 
cases of the kind. It probably acts by its tonic properties rather than 
in the manner Simpson supposed. It may be given in doses of fifteen 
to twenty grains three times a day, and may be advantageously com- 
bined with small doses of dilute hydrochloric acid. In frequently 
recurring premature labors with dead children, Simpson strongly 
recommended the induction of premature labor a little before the time 
at which we had reason to believe that the foetus had usually perished; 
or, in other words, before the placental disease had advanced sufficiently 
far to interfere with its nutrition. The practice has constantly been 
adopted with success, and is perfectly legitimate, btit the difficulty, of 
course, is to fix on the right time. Careful auscultation of the foetal 
heart may be of some use in guiding us to a decision, as the death of 
the foetus is generally preceded for some days by irregular, tumultuous, 
and intermittent action of the heart. 

There will always remain a certain number of cases in which no 
appreciable cause can be discovered. Under such circumstances pro- 
longed rest, at least until the time has passed at which abortion 
formerly took place, will afford the best chance of avoiding a recur- 
rence of the accident. There must always be some difficulty in carry- 
ing out this indication, inasmuch as the patient's health is apt to suffer 
in other ways from the confinement, and the want of fresh air and 
exercise which it entails. The strictness with which rest should be 
insisted on must vary in different cases, but it should be specially 
attended to at what -would have been the menstrual periods. At these 
times the patient should remain in bed altogether ; at others she may 
lie on a sofa, and, if circumstances permit, spend part of the day at 
least in the open air. Sexual intercourse should be prohibited. 
Should actual symptoms of abortion come on, the preventive treat- 
ment, already indicated, may be resorted to. Great care, however, 
should be used in prescribing opiates as preventives, and they should 
be given for a specified time only. I have seen, more than once, an 
incurable habit of opium-eating originate from the incautious and too 
lono;-eontmued exhibition of the drug in such cases. 

When we have satisfied ourselves that abortion is inevitable, we 



262 PREGNANCY. 

must proceed to employ treatment that favors the expulsion of the 
ovum. 

If the os be sufficiently dilated, and the pains strong, we may find 
the ovum separated and protruding from the os. We may then be 
able to detach it by the finger. For this purpose the uterus is de- 
pressed from without by the left hand, while an endeavor is made to 
scoop out the ovum with the examining finger. If it be out of reach 
and yet appear detached, chloroform should be administered, the 
whole hand introduced into the vagina, and the finger into the uterine 
cavity. The complete detachment of the ovum can, in this way, be 
far more readily and safely effected than by using any of the many 
ovum forceps which have been invented for the purpose. 

If the ovum be not sufficiently separated or the os be undilated, 
means must be taken to control the hemorrhage until the former can 
be removed or expelled. It is here that plugging of the vagina finds 
its most useful application. This may be done in various ways. That 
most usually employed is filling the vagina with a tolerably large 
sponge, in the interstices of which the blood coagulates. A better 
plan is to soak a number of pledgets of cotton- wool in carbolized water 
and tie a string around each. The vagina can be completely and 
effectively packed with these ; and this is best done through a speculum, 
or, better still, with the aid of a duck-bill speculum, the patient being 
placed on her left side. Each pledget should be covered with glycerin, 
which completely prevents the offensive odor which otherwise always 
arises. The pledgets can be removed by traction on the strings, but if 
these are not used much pain is caused in getting them out of the vagina. 
The plug should never be left in for more than six or eight hours, after 
which a fresh one may be inserted if necessary. Two or three full 
doses of the liquid extract of ergot, of half an ounce to an ounce each, 
or a subcutaneous injection of ergotine, may be given while the plug is 
in position. The plug itself is a strong excitant of uterine action, and 
the two combined often effect complete detachment, so that, on the 
removal of the tampon, the ovum may be found lying loose in the os 
uteri. If the os be undilatecl and the ovum entirely out of reach, the 
former may be opened by means of sponge or laminaria tents, or by 
Hegar's dilators. I think a well-prepared sponge tent the most 
effectual, and it can be maintained in situ by a vaginal plug below it. 
It also acts as a most efficient plug, effectually controlling all hemor- 
rhage. In a few hours it opens up the os sufficiently to admit the 
finger. 

The most troublesome cases are those in which the foetus is first 
expelled, and the placenta and membranes remain in utero. As long 
as this is the case the patient can never be considered safe from the 
occurrence of septicaemia. Dr. Priestley has strongly insisted on the 
importance of removing the secundines as soon as possible. There 
can be no doubt that this should be done whenever it is feasible. 
Cases, however, are frequently met with in which any forcible attempt 
at removal would be likely to prove very hurtful, and in which it is 
better practice to control hemorrhage by the plug or sponge tent, and 
wait until the placenta is detached, which it will generally be in a 



ABORTION AM) PREMAT1 KB LABOR. 263 

day or two at most. Under such circumstances fcetor and decomposi- 
tion of the Becundines may be prevented by intra-uterine antiseptic 
injections. Provided the os be sufficiently patulous to prevent the 
collection of t lu> fluid in the uterine cavity, and not more than a 
drachm or two of fluid be injected at a time, so as Bimply to wash away 
and disinfect decomposing detritus, they can be \\<vd with perfect 
safety. Sometimes cases are met with in which the os has entirely 
closed, and in which we can only suspect the retention of the placenta 
by the history of the case, the continuance of hemorrhage, or the 
presence of a fetid discharge. Should we see reason to suspect this, 
the OS must be dilated and the uterine cavity thoroughly explored 
under chloroform. This condition of things is far from uncommon 
in women who have not had medical assistance from the first, and it 
often gives rise to very troublesome and anxious symptoms. It has 
been said that placentae thus retained have been completely absorbed, and 
cases of the kind have been related by Naegele and Osiander. The 
spontaneous absorption, however, of so highly organized a body as the 
placenta would be a phenomenon of the most remarkable character ; 
and it seems more natural to suppose that, in most cases of the kind, 
the placenta has been cast off without the knowledge of the patient. 
Sometimes the placenta never becomes entirely detached, and, retaining 
organic connection with the uterine walls, forms what has been called a 
" placental polypus. This may produce secondary hemorrhages, in the 
same way as an ordinary fibroid polypus. Barnes recommends the 
removal of these masses by means of the wire ecraseur. Before their 
detection the os uteri must be opened up. 

Retention in Utero of a Blighted Ovum. — The cases previously 
alluded to, in which an ovum has perished in early pregnancy and is 
retained in utero, are often puzzling and may give rise to serious 
moral and medico-legal questions. The blighted ovum may be re- 
tained for many months, the outside limit, according to McClintock, 1 
by whom the subject has been ably discussed, being nine months. 
The appearance of the ovum when thrown off will give no reliable 
clue to the length of time which has elapsed since it perished. The 
symptoms are often very obscure. Generally there have been the usual 
indications of pregnancy which, with or without signs of impending 
miscarriage, disappear or are modified, and then follows a period of 
ill-health, with pelvic uneasiness, and irregular metrorrhagia, which 
may be mistaken for menstruation. Occasionally, but by no means 
necessarily, there is a foetid discharge, and this probably exists only 
when the membranes have broken, and air has access to the ovum. 
In some cases obscure septicemic symptoms have been observed. 
Such symptoms are obviously too indefinite to lead to an accurate 
diagnosis. In the course of time the ovum is generally thrown off, 
with more or less hemorrhage. If the nature of the case is detected, 
ergot may be given to promote the expulsion of the uterine contents, 
and it may even be advisable to dilate the cervix with sponge or 
laminaria tents and remove them artificially. 

J Sydenham Society's edition of Srnellie's Midwifery, vol. i. p. 169. 



264 PEEGXANCY. 

Subsequent Management of Abortion. — The frequency with 
which abortion leads to chronic uterine disease should lead us to 
attach much more importance to the subsequent management of the 
patient than has been customary. The usual practice is to confine the 
patient to bed for two or three days only, and then to allow her to 
resume her ordinary avocations, on the supposition that a miscarriage 
requires less subsequent care than a confinement. The contrary of this 
is, however, most probably the case ; for the uterus has been emptied 
when it is unprepared for involution, and that process is often very 
imperfectly performed. We should, therefore, insist on at least as 
much attention being paid to rest as after labor at term. 



PART III 

LABOR. 



CHAP TEE I. 

THE PHENOMENA OF LABOR. 

Delivery at Term. — In considering delivery at term we Lave to 
discuss two distinct classes of events. 

One of these is the series of vital actions brought into play in order 
to effect the expulsion of the child ; and the other consists of the move- 
ments imparted to the child — the body to be expelled — in other words, 
the mechanism of delivery. 

Causes of Labor. — Before proceeding to the consideration of these 
important topics, a few words may be said as to the determining causes 
of labor. This subject has been from the earliest times a qucestio vexata 
among physiologists ; and many and various are the theories which 
have been broached to explain the curious fact that labor sponta- 
neously commences, if not at a fixed epoch, at any rate approximately 
so. It must be admitted that even yet there is no explanation which 
can be implicitly accepted. 

The explanations which have been given may be divided into two 
classes — those which attribute the advent of labor to the foetus, and 
those which refer it to some change connected with the maternal gen- 
erative organs. 

The former is the opinion which was held by the older accoucheurs, 
who assigned to the foetus some active influence in effecting its own 
expulsion. It need hardly be said that such fanciful views have no 
kind of physiological basis. Others have supposed that there might 
be some change in the placental circulation, or in the vascular system 
of the foetus, which might solve the mystery. 

The majority of obstetricians, however, refer the advent of labor to 
purely maternal causes. Among the more favorite theories is one, 
which was originally started in this country [i. e., England] by Dr. 
Power, and adopted and illustrated by Depaul, Dubois, and other 
writers. It is based on the assumption that there is a sphincter action 
of the fibres of the cervix, analogous to that of the sphincters of the 
bladder and rectum, and that when the cervix is taken up into the 
general uterine cavity as pregnancy advances, the ovum presses upon 
it, irritates its nerves, and so sets up reflex action, which ends in the 
establishment of uterine contraction. This theory was founded on 
erroneous conceptions of the changes that occurred in the neck of the 

265 



266 LABOR. 

uterus ; and, as it is certaiu that obliteration of the cervix does uot 
really take place iu the manner that Power believed when his theory 
was broached, it is obvious that its supposed result cannot follow. A 
modification of this theory is that held by Stoltz and Bandl. Accord- 
ing to this view, when the cervix softens during the last weeks of 
pregnancy, the painless uterine contractions of gestation act upon the 
os internum, and open it sufficiently to admit of the ovum pressing on 
the lower segment of the uterus, and so inducing labor. 

Girin 1 contends that the descent and pressure of the foetal head on 
the os internum is favored by changes in the density of the liquor 
amnii. This attains its maximum density in the early months of 
pregnancy, when it is 1.030, and it diminishes steadily until term, 
when it is nearly that of water. The specific gravity of the foetus is 
at first lower than that of the amniotic fluid, but becomes steadily 
higher. Eventuallv the foetus, sinking on the os internum, excites the 
uterus to contraction. 

Extreme distention of the uterus has been held to be the determining 
cause of labor, a view lately revived by Dr. King, of Washington, 2 who 
believes that contractions are induced because the uterus ceases to aug- 
ment in capacity, while its contents still continue to increase. This 
hypothesis is sufficiently disproved by a number of clinical facts which 
show that the uterus may be subject to excessive and even rapid dis- 
tention — as in cases of hydramnios, multiple pregnancy, and hydatidi- 
form degeneration of the ovum — without the supervention of uterine 
contractions. 

Another inciter of uterine action has been supposed to be the sepa- 
ration of the ovum from its connection to the uterine parietes, in 
consequence of fatty degeneration of the decidua occurring at the end 
of pregnancy. The supposed result of this change, which undoubtedly 
occurs, is that the ovum becomes so detached from its organic adhe- 
sions as to be somewhat in the position of a foreign body, and thus 
incites the nerves so largely distributed over the interior of the uterus. 
This theory, which has been widely accepted, was originally started by 
Sir James Simpson, who pointed out that some of the most efficient 
means of inducing labor (such, for example, as the insertion of a gum- 
elastic catheter between the ovum and the uterine walls) probably act 
in the same way, viz., by effecting separation of the membranes and 
detachment of the ovum. 

Barnes instances, in opposition to this idea, the fact that ineffectual 
attempts at labor come on at the natural term of gestation in cases of 
extra-uterine pregnancy, when the foetus is altogether independent of 
the uterus, and, therefore, he argues, the cause cannot be situated in 
the uterus itself. A fair answer to this argument would be that 
although, in such cases, the wonib does not contain the ovum, it does 
contain a decidua, the degeneration and separation of which might suf- 
fice to induce the abortive and partial attempts at labor then witnessed. 

Leopold 3 suggests that the advent of labor may be connected with 

1 Arch, de Tocologie, Xo. 8, 1889. 

2 American Journal of Obstetrics, 1S70-71, vol. iii. p. 561 

3 " Studien tiber die Schleimbaut," etc. Arch. f. Gyn., 1SS7, Bd. xi. s. 443. 



THK r II BNO M KX A OP l.A BO R . 261 

other changes in the decidua which occur in advanced pregnancy. He 
points out that then giant cells, containing many nuclei, appear in the 
scroti na which penetrate the uterine sinuses, and cause the formation 
in them of thrombi. The obstruction in the calibre of a Dumber of 
these vessels leads to a stasis of the maternal blood returning from the 
placenta, and to an increase of carbonic acid in it, which may excite 
the motor centre for uterine contraction, which is known to exisl in 
the medulla oblongata. 

Objections to These Theories. — A. serious objection to all these 
theories, which are based on the assumption that some local irritation 
brings on contraction, is the fact, which has not been generally appre- 
ciated, that uterine contractions are always present during pregnancy 
as a normal occurrence, and that they may be, and often are, readily 
intensified at any time, so as to result in premature delivery. 

It is, indeed, most likely that, at or about the full term, the nervous 
supply of the uterus is so highly developed, and in so advanced a state 
of irritability, that it more readily responds to stimuli than at other 
times. If, by separation of the decidua, or in some other way, stimu- 
lation of the excitor nerves is then effected, more frequent and forcible 
contractions than nsnal may result, and, as they become stronger and 
more regular, terminate in labor. But, allowing this, it still remains 
quite unexplained why this should occur with such regularity at a 
definite time. 

Tyler Smith tried, indeed, to prove that labor came on naturally at 
what would have been a menstrual epoch, the congestion attending the 
menstrual nisus acting as the exciter of uterine contraction. He 
therefore refers the onset of labor to ovarian, rather than to uterine, 
causes. Although this view is upheld with all its author's great 
talent, there are several objections to it difficult to overcome. Thus, 
it assumes that the periodic changes in the ovary continue during 
pregnancy, of which there is no proof. Indeed, there is good reason 
to believe that ovulation is suspended during gestation, and with it, of 
course, the menstrual nisus. Besides, as has been well objected to by 
Cazeaux, even if this theory were admitted, it would still leave the 
mystery unsolved, for it would not explain why the menstrual nisus 
should act in this way at the tenth menstrual epoch, rather than at the 
ninth or eleventh. 

In spite, then, of many theories at our disposal, it is to be feared 
that we must admit ourselves to be still in entire ignorance of the 
reason why labor should come on at a fixed epoch. 

Mode in which the Expulsion of the Child is Effected. — The 
expulsion of the child is effected by the contractions of the muscular 
fibres of the uterus, aided by those of some of the abdominal muscles. 
These efforts are in the main entirely independent of volition. So far 
as regards the uterine contractions, this is absolutely true, for the 
mother has no power of originating, lessening, or increasing the action 
of the uterus. As regards the abdominal muscles, however, the mother 
is certainly able to bring them into action, and to increase their power 
by voluntary efforts; but, as labor advances, and as the head passes 
into the vagina aud irritates the nerves supplying it, the abdominal 



268 LABOR. 

muscles are often stimulated to contract, through, the influence of reflex 
action, independently of volition on the part of the mother. 

There can be little doubt that the chief agent in the expulsion of the 
child is the contraction of the uterus itself. This opinion is almost 
unanimously held by accoucheurs, and the influence of the abdominal 
muscles is believed to be purely accessory Dr. Haughton, 1 however, 
maintains a view which is directly contrary to this. From an ex- 
amination of the force of the uterine contractions, arrived at by 
measuring the amount of muscular fibre contained in the walls of the 
uterus, he arrives at the conclusion that the uterine contractions are 
chiefly influential in rupturing the membranes, and dilating the os 
uteri, bringing into action, if needful, a force equivalent to 54 pounds ; 
but when this is effected, and the second stage of labor has commenced, 
he thinks the remainder of the labor is mainly completed by the con- 
tractions of the abdominal muscles, to which he attributes enormous 
powers, equivalent, if needful, to a pressure of 523.65 pounds on the 
area of the pelvic canal. 

These views bear on a topic of primary consequence in the physi- 
ology of labor. They have been fully criticised by Dimcan, who has 
devoted much experimental research to the study of the powers brought 
into action in the expulsion of the child. His conclusions are that, so 
far from the enormous force being employed that Haughton estimated, 
in the large majority of cases the effective force brought to bear on the 
child by the combined action of both the uterine and abdominal mus- 
cles is less than 50 pounds — that is, less than the force which Haughton 
attributed to the uterus alone. In extremely severe labors, when the 
resistance is excessive, he thinks that extra power may be employed , 
but he estimates the maximum as not above 80 pounds, including in this 
total the action of both the uterine and abdominal muscles. Joulin 
arrived at the conclusion that the uterine contractions Avere capable of 
resisting a maximum force of about one hundredweight. Both these 
estimates, it will be observed, are much under that of Haughton, which 
Duncan describes as representing " a strain to which the maternal 
machinery could not be subjected without instantaneous and utter 
destruction." 

There are many facts in the history of parturition which make it 
certain that the chief factor in the expulsion of the child is the uterus. 
Among these may be mentioned occasional cases in which the action of 
the abdominal muscles is materially lessened, if not annulled — as in 
profound anaesthesia, and in some cases of paraplegia — in which, 
nevertheless, uterine contractions suffice to effect delivery. The most 
familiar example of its influence, however, and one that is a matter of 
everyday observation in practice, is Avhen inertia of the uterus exists. 
In such cases no effort on the part of the mother, no amount of 
voluntary action that she can bring to bear on the child, has any 
appreciable influence on the progress of the labor, which remains in 
abeyance until the defective uterine action is re-established, or until 
artificial aid is given. 

i '• On the Muscular Forces Employed in Parturition," etc. Dubiiu Quart. Journ. Med. Sc, 1870, 
vol. xlxi. p. 459. 



THE PHENOMENA OP LABOR. 269 

Contraction of the uterus, then, being the main agent in delivery, it 

is important for us to appreciate its mode of action, and its effect on 
the ovum. 

Uterine Contractions at the Commencement of Labor. — We 
have soon that intermittent and generally painless uterine contractions 
exist during pregnancy. As the period for delivery approaches, these 
become more frequent and intense, until labor actually commences, 
when they begin to l>o sufficiently developed to effect the opening up 
of the os uteri, with a view to the passage of the child. They are now 
accompanied by pain, which increases as labor advances, and is SO 
characteristic that "pains" are universally used as a descriptive term 
for the contractions themselves. It does not necessarily follow that 
uterine contractions are painless until they commence to effect dilata- 
tion of the os uteri. On the contrary, during the last days or even 
weeks of pregnancy, women constantly have irregular contractions, 
accompanied by severe suffering, which, however, pass off without pro- 
ducing any marked effect on the cervix. When labor has actually 
begun, if the hand is placed on the uterus, when a pain commences, 
the contraction of its muscular tissue is very apparent, and the whole 
organ is observed to become tense and hard, the rigidity increasing 
until the pain has reached its acme, the uterine Avails then relaxing, 
and remaining soft until the next pain comes on. At the commence- 
ment of labor these pains are few, separated from each other by a con- 
siderable interval, and of short duration. In a perfectly typical labor 
the interval between the pains becomes shorter and shorter, while, at 
the same time, the duration of each pain is increased. At first they 
may occur only once in an hour or more, while eventually there may 
not be more than a few minutes' interval between them. 

If, when the pains are fairly established, a vaginal examination be 
made, the os uteri may be found to be thinned and dilated in propor- 
tion to the progress of the labor. During the contraction the bag of 
membranes will be felt to bulge, to become tense from the downward 
pressure of the liquor amnii within it, and to protrude through the 
os if it be sufficiently open. The membranes, with the contained 
liquor amnii, thus form a fluid wedge, which has a most important 
influence in dilating the os uteri (see Frontispiece). This does not, 
however, form the sole mechanism by which the os uteri is dilated, for 
it is also acted upon by the contractions of the muscular fibres of the 
uterus, which tend to pull it open. It is probable that the muscular 
dilatation of the os is effected chiefly by the longitudinal fibres, which, 
as they shorten, act upon the os uteri, the part where there is least 
resistance. 

Partly then by muscular contraction, partly by mechanical pressure, 
the cervical canal is dilated, and as it opens up it becomes thinner and 
thinner, until it is entirely taken up into the uterine cavity. 

There is no longer any obstacle to the passage of the presenting part 
of the child into the cavity of the pelvis, and the force of the pains 
now generally effects the rupture of the membranes, and the escape of 
the liquor amnii. There is often observed, at this time, a temporary 
relaxation in the frequency of the pains, which had been steadily 



270 LABOR. 

increasing ; but they soon recommence with increased vigor. If the 
abdomen be now examined, it will be observed to be much diminished 
in size, partly in consequence of the escape of the liquor amnii, partly 
from the descent of the foetus into the pelvic cavity. 

The character of the pains soon changes. They become stronger, 
longer in duration, separated by a shorter interval, and accompanied 
by a distinct forcing effort, being generally described as " the bearing 
down" pains. ]Sow is the time at which the accessory muscles of 
parturition come into operation. The patient brings them into play in 
the manner which will be subsequently described, and the combined 
action of the uterine and abdominal muscles continues until the expul- 
sion of the child is effected. 

The precise mode of uterine contraction is still somewhat a matter 
of dispute. It is generally described as commencing in the cervix, 
passing gradually upward by peristaltic action, the wave then returning 
downward toward the os uteri. This view was maintained by "Wlgand, 
and has been indorsed by Bigby, Tyler Smith, and many other writers. 
In support of it they instance the fact that, on the accession of a pain, 
the presenting part first recedes, the bag of membranes then becomes 
tense and protrudes through the os, and it is not until some time that 
the presenting part of the child itself is pushed down. It is very 
doubtful if this view is correct ; and a careful examination of the course 
of the pains would rather lead to the belief that the contractions com- 
mence at the fundus, where the muscular tissue is most largely de- 
veloped, and gradually proceed downward to the cervix, the waves of 
contraction being, however, so rapid that the whole organ seems to 
harden en masse. The apparent recession of the presenting part, and 
the bulging of the bag of membranes, are certainly no proof that the 
contractions begin at the cervix ; for the commencing contraction would 
necessarily push down the fluid in front of the head, and cause the 
membranes to bulge, and the os to become tense, before its force was 
brought to bear on the foetus itself. Indeed, did the contraction com- 
mence at the lower part of the uterus, we should expect the opposite of 
what takes place to occur, and the waters to be pushed upward, 
and away from the cervix. The fundal origin of the contraction is 
further illustrated by what is observed when the hand of the accoucheur 
is placed in the uterine cavity, as often happens in certain cases of hem- 
orrhage or turning ; for if a pain then comes on, it will be felt to start 
at the fundus, and gradually compress the hand from above downward. 

Value of the Intermittent Character of the Pains. — The inter- 
mittent character of the contractions is of great practical importance. 
Were they continuous, not only would the muscular powers of the 
patient be rapidly exhausted, but by the obliteration of the vessels 
produced by the muscular contraction, the circulation through the 
placenta would be interfered with, and the life of the child imperilled. 
Hence one of the chief dangers of protracted labor, especially after the 
escape of the liquor amnii, is that the uterine fibres may enter into a 
state of tonic rigidity, a condition that cannot be long continued with- 
out serious risks both to the mother and child. 

The fact that the uterine contractions are altogether involuntary 



THE PHENOMENA OF LABOR. 271 

proves them to be excited — as indeed we would a priori infer from our 
know Ledge of the anatomical arrangement of the nerves of the uterus — 
solely by the sympathetic Bystem. Still it is a fact of everyday obser- 
vation that they can be largely influenced by emotions. Various 
stimuli applied to the spinal system of nerves (as, for example, when 
the mammae are irritated) havealsoa marked effect in inducing uterine 
contraction. The precise mode in which such influence is conveyed to 
the uterus, in spite of the numerous experiments which have been 
made for the purpose of determining how far labor is affected by 
destruction of the spinal cord, is still a matter of doubt. After the 
fetus has passed through the cervix, the spinal nerves distributed to 
the vagina and perineum are excited by the pressure of the pre- 
senting part, and through them the accessory powers of parturition are 
chiefly brought into play. The contraction of the muscles of the 
vagina itself is supposed to have some influence in favoring the ex- 
pulsion of the foetus after the birth of part of the body, and also in 
promoting the expulsion of the placenta. In the lower animals the 
vagina has a very marked contractile property, and is, in some of them, 
the main agent by which the young are expelled. In the human 
subject this influence is certainly of very secondary importance. 

Character and Sources of Pains During- Labor. — The amount of 
suffering experienced during labor varies much in different cases, and 
is in direct proportion to the nervous susceptibility of the patient. 
There are some women who go through labor with little or no pain at 
all. This is proved by the cases (of which there are numerous authentic 
instances recorded) in which labor has commenced during sleep, and 
the child has been actually born without the mother awakening. I am 
acquainted with a lady, who has had a large family, Avho assures me 
that, though labor is accompanied by a sense of pressure and dis- 
comfort, she experiences nothing which can be called actual pain. Such 
a happy state of affairs is, however, extremely exceptional, and, in the 
vast majority of cases, parturition is accompanied by intense suffering 
during its whole course, in some cases amounting to anguish which has 
probably no parallel under any other condition. 

The precise cause of the pain has been much discussed, and is, no 
doubt, complex. 

In the early stage of labor, and before the dilatation of the os, it is 
chiefly seated in the back, from whence it shoots around the loins and 
down the thighs. It is then probably produced, partly by pressure 
on the nerve-filaments caused by contraction of the muscular fibres to 
which they are distributed, and partly by stretching and dilatation of 
the muscular tissue of the cervix. M. Beau believes that in this stage 
the pain is not produced, strictly speaking, in the uterus itself, but is 
rather a neuralgia of the lumbo-abdominal nerves. The pains at this 
time are generally described as " acute" and " grinding," terms which 
sufficiently well express their nature. In highly nervous women these 
pains are often much less well borne than those of a later stage, and 
the suffering they undergo is indicated by their extreme restlessness 
and loud cries as each contraction supervenes. As the os dilates, and 
the labor advances into the expulsive stage, other sources of suffering 
are added. 



272 LABOR. 

The presenting part now passes into the vagina and presses on the 
vaginal nerves, as well as on the large nervous plexuses lying in the 
pelvis. As it descends lower it stretches the perineum and vulva, and 
presses on the bladder and rectum. Hence cramps are produced in 
the muscles supplied by the nerve plexuses, as well as an intolerable 
sense of tearing and stretching in the vulva and perineum, and often 
a distressing feeling of tenesmus in the bowels. Bv this time the 
accessory muscles of parturition are brought into action, and they, as 
well as the uterine muscles, are thrown into frequent and violent con- 
tractions, which, independently of the other causes mentioned, are 
sufficient of themselves to produce great pain, likened to that of colic, 
produced by involuntary and repeated contraction of the muscles of 
the intestines. 

Taking all these causes into consideration, there is no lack of suffi- 
cient explanation of the intolerable suffering which is so constant an 
accompaniment of childbirth. 

Effect of the Pains on the Mother and Foetus. — The effect of the 
pains on the mother's circulation is well marked. The rapidity of the 
pulse increases distinctly with each contraction, and, as the pain passes 
off, it again declines to its former state. A similar observation has 
been made with regard to the sounds of the foetal heart, especially after 
the expulsion of the liquor amnii. Hicks has pointed out that during 
a pain the muscular vibrations give rise to a sound which often 
resembles that of the foetal heart, and which completely disappears 
when the muscular tissue relaxes. The effect of the pain in intensi- 
fying the uterine souffle has been already mentioned. The strong 
muscular efforts would naturally lead us to expect a marked elevation 
of temperature during labor. Further observations on this point are 
required ; but Squire asserts that there is generally only a very slight 
increase in temperature during delivery, rapidly passing off as soon as 
labor is over. 

Division of Labor into Stages. — Such being the physiological 
facts in connection with the labor pains, we may now describe the 
ordinary progress of a natural labor — that is, one terminated by the 
natural powers, and with a head presenting. 

For facility of description obstetricians have long been in the habit 
of dividing the course of labor into stages, which correspond pretty 
accurately with the natural sequence of events. For this purpose we 
generally talk of three stages : viz. (1) from the commencement of 
regular pains until the complete dilatation of the cervix {stage of efface- 
ment and dilatation) ; (2) from the complete dilatation of the cervix 
imtil the expulsion of the child (stage of expulsion) ; (3) the concluding 
stage, comprising the permanent contraction of the uterus, and the 
separation and expulsion of the placenta (stage of the after-birth). To 
these we may conveniently add a preparatory stage, antecedent to the 
regular commencement of the labor. 

Preparatory Stage. — For a short time before delivery, varying 
from a few days to a week or two, certain premonitory symptoms 
generally exist, which indicate the approaching advent of labor. Some- 
times they are well marked, and cannot be mistaken ; at others they 



THE PHENOMENA OF LABOR. 27^ 

are so slight as to escape observation. Amongst the most common is 
a sinking of the uterus into the pelvic cavity, resulting from the relax- 
ation of the soft parts preceeding delivery. The result is that the 
upper edge of the uterine tumor is less high than before, and in con- 
sequence the pressure on the respiratory organs is diminished, and 
the woman often feels lighter and altogether less unwieldy than in 
the previous weeks. If a vaginal examination be made at this time, 
the lower segment of the uterus will be found to have sunk lower into 
the pelvic cavity ; and the consequence of this is that, while the respira- 
tion is less embarrassed and the patient feels less bulky, other accom- 
paniments of pregnancy, such as hemorrhoids, irritability of the 
bladder and bowels, and oedema of the limbs, become aggravated. 
The increased pressure on the bow r els often induces a sort of temporary 
diarrhoea, which is so far advantageous that it empties the bowels of 
feces which may have collected within them. As has already been 
pointed out, the contractions which have been going on at intervals 
during the latter months of pregnancy now get more and more marked, 
and they have the effect of producing a real shortening of the cervix, 
which is of great value preparatory to its dilatation. More marked 
mucous discharge from the cavity of the cervix also generally occurs 
a short time before labor, and it is not infrequently tinged with blood 
from the laceration of minute capillary vessels. The discharge, popu- 
larly known as the "shows" is a pretty sure sign that labor is not far 
oif. It may, however, be entirely absent, even until the birth of the 
child. When copious, it serves to lubricate the passages, and is 
generally coincident with rapid dilatation of the parts and a speedy 
labor. 

During this time [premonitory stage) painful uterine contractions are 
often present, which, however, have no effect in dilating the cervix. 
In some cases they are frequent and severe, and are very apt to be 
mistaken for the commencement of real labor. Such "false pains" as 
they are termed, are often excited and kept up by local irritations, 
such as a loaded or disordered state of the intestinal canal ; and they 
frequently give rise to considerable distress, and much inconvenience 
both to the patient and practitioner. They are, it should be remem- 
bered, only the normal contractions of the uterus intensified and accom- 
panied with pain. 

First Stage, or Dilatation. — As labor actually commences, the 
uterine contractions become stronger, and the fact that they are " true" 
pains can be ascertained by their effect on the cervix. If a vaginal 
examination be made during one of these, the membranes will be felt 
to become tense and bulging during the pain, and the os uteri will be 
found partially dilated, and thinned at its edges. As labor advances 
this effect on the os becomes more and more marked. At first the 
dilatation is very slight, perhaps not more than enough to admit the 
tip of the examining finger, and both the upper and lower orifices of 
the cervix can be made out. As the pains get stronger and more fre- 
quent, dilatation proceeds in the way already described, and the cervix 
gets more thin and tense, until we can feel a thin circular ring (which 
is lax between the pains, but becomes rigid and tense during the 

18 



274 LABOR. 

contraction when the bag of waters bulges through it), without any 
distinction between the upper and lower orifices. During this time 
the patient, although she may be suffering acutely, is generally able 
to sit up and walk about. The amount of pain experienced varies 
much according to the character of the patient. In emotional women 
of highly developed nervous susceptibilities it is generally very great. 
They are restless, irritable, and desponding, and when the pain comes 
on cry out loudly. The character of the cry is peculiar and well 
marked during the first stage, and has constantly been described bv 
obstetric writers as characteristic. It is acute and high, and is cer- 
tainly very different from the deep groans of the second stage, when 
the breath is involuntarily retained to assist the parturient effort. 
When dilatation is nearly completed various reflex nervous phenomena 
often show themselves. One of these is nausea and vomiting, another 
is uncontrollable shivering, which is not accompanied by a sense of 
coldness, the patient being often hot and perspiring. Both these 
symptoms indicate that the propulsive stage will shortly commence ; 
and they may be regarded as favorable rather than otherwise, although 
they are apt to alarm the patient and her friends. By this time the 
os is fully dilated, the membranes generally rupture spontaneously, and 
a considerable portion of the liquor amnii flows away. The head, if 
presenting, often acts as a sort of ball-valve, and, falling down on 
the aperture of the cervix, prevents the complete evacuation of the 
liquor amnii, which escapes by degrees during the rest of the labor, 
or may be retained in considerable quantity until the birth of the 
child. 

It not infrequently happens, if the membranes are somewhat tougher 
than usual and the pains frequent and strong, that the foetus is pushed 
through the pelvis, and even expelled surrounded by the membranes. 
When this occurs the child is said to be born with a " caul" and this 
event would doubtless happen more frequently than it does were it not 
the custom of the accoucheur to rupture the membranes artificially as 
soon as the os is completely opened up, after which time their integrity 
is no longer of any value. 

Second Stage, or Propulsion. — The os is now entirely retracted 
over the presenting part, and is no longer to be felt, the vagina and 
the uterine cavity forming a single canal. Xow the mucous discharge 
is generally abundant, so that the examining finger brings away long 
strings of glairy, transparent mucus tinged with blood. The pains, 
after a short interval of rest, become entirely altered in character. 
The uterus contracts tightly round the foetus, the presenting part 
descends into the pelvis, and the true propulsive pains commence. 
The accessory muscles of parturition now come into play. With each 
pain the patient takes a deep inspiration, aucl thus fills the chest so as 
to give a point d'appui to the abdominal muscles. For the same 
reason she involuntarily seizes hold of some point of support, as the 
hand of a bystander or a towel tied to the bed, and, at the same time, 
pushes with her feet against the end of the bed, and so is able to bear 
down to advantage. The cries are no longer sharp and loud, but 
consist of a series of deep suppressed groans, which correspond to a 



THE PHENOMENA OF LABOR. 275 

succession of short expirations made during the straining effort. In 
this way tlu i abdominal muscles contract forcibly on the uterus, which 
they further stimulate to action by pressing upon it. It is to be 
observed that these straining efforts are, toa considerable extent, under 

the control of the patient. By encouraging her to hold her breath 
and hear down they can he intensified ; while if we wish to lessen 
them we can advise her to call out, and when she does so the abdom- 
inal muscles have no longer a fixed point of action. Although the 
patient may thus lessen the effect of these accessory muscles, it is 
entirely out of her power to stop their action altogether. As labor 
advances the head descends lower and lower, receding somewhat in the 
intervals between the pains, until eventually it comes down on the 
perineum, which it soon distends. 

The pains now get stronger and more frequent, often with scarcely 
a perceptible interval between them, until the perineum gets stretched 
by the advancing head. In the interval between the pains the elas- 
ticity of the perineal structures pushes the head upward, so as to 
diminish the tension to which the perineum is subjected, the next pain 
again putting it on the stretch and protruding the head a little further 
than before. By this alternate advance and recession the gradual 
yielding of the structures is favored and risk of laceration greatly 
diminished. During this time the pressure of the head mechanically 
empties the bowel of its contents. During the last pains, when the 
perineum is stretched to the utmost, the anal aperture is dilated, some- 
times to the size of a [silver dollar] ; and in this way the perineum 
is relaxed, just as the distention, and consequent risk of laceration, 
are at their maximum. The apex of the head now protrudes more 
and more through the vulva, surrounded by the orifice of the vagina, 
and eventually it glides over the perineum and is expelled. The in- 
tensity of the suffering at this moment generally causes the patient to 
call out loudly. The force of the abdominal muscles is thus lessened 
at the last moment, and this, in combination with the relaxation of 
the sphincter ani, forms an admirable contrivance for lessening the 
risk of perineal injury. The rest of the body is generally expelled 
immediately by a single pain, and with, it are discharged the remains 
of the liquor amnii, and some blood-clots from separation of the 
placenta ; and so the second stage of labor terminates. 

The Third Stage. — The third stage commences after the expulsion 
of the child. It is of paramount importance to the safety of the 
mother that it should be conducted in a natural and efficient manner ; 
for it is now that the uterine sinuses are closed, and the frail barrier 
by which nature effects this may be very readily interfered with, and 
serious and even fatal loss of blood ensue. Unfortunately, it is too 
often the ease that the practitioner's entire attention is fixed on the 
expulsion of the child, so that the natural history of the rest of delivery 
is very generally imperfectly studied and understood. 

As soon as the child is expelled, the uterine fibres contract in all 
directions, and the hand, following the uterus down, will find that it 
forms a firm rounded mass lying in the lower part of the abdominal 
cavity. By retraction of its internal surface the placental attachments, 



276 



LABOR. 



which probably remain undisturbed until the expulsion of the child, 
are generally separated, and the after-birth remains in the cavity of 
the uterus as a foreign body. 

The escape of blood from the open mouths of the uterine sinuses 
is now prevented in two ways, viz. : (1) by the contractions of the 
uterine walls, and the more firm, persistent, and tonic this is, the more 
certain is the immunity from hemorrhage ; (2) by the formation of 
coagula in the mouths of the vessels. Any undue haste in promoting 
the expulsion of the placenta tends to prevent the latter of these two 
haemostatic safeguards, and is apt to be followed by loss of blood. 
After a certain time, averaging from a quarter to half an hour, the 
uterus will be felt to harden, and, if the case be solely left to Nature, 
what has been aptly called a miniature labor occurs. Pains come on, 
and the placenta is spontaneously expelled from the uterus, either into 
the canal of the vagina or even externally. In most obstetric works 
it is stated that the after-birth may be separated either from its centre 
or edge, and that it is very generally expelled through the os in an 
inverted form, with its foetal surface downward, and folded transversely 
on itself. That this is the mode in which the placenta is often ex- 
pelled, when traction on the cord is practised, is a matter of certainty. 
It then passes through the os very much in the shape of an inverted 
umbrella. It is certain, however, that this is not the natural mechanism 
of its delivery. The subject has been well studied by Berry Hart, 1 
who has shown that during the contractions of the third stage of labor 
the placenta is " thrown into heights and hollows," and, if the case 
be left entirely to Nature, it descends with its 
edge or a point near its edge first, its uterine 
and detached surface gliding along the inner 
surface of the uterus, the foldings of its structure 
being parallel to the long diameter of the uterine 
cavity (Fig. 100). In this way it is expelled 
iuto the vagina, and during the process little 
or no hemorrhage occurs. AVhen the placenta is 
drawn out in the way too generally practised, it 
obstructs the aperture of the os, and, acting like 
the piston of a pump, tends to promote hemor- 
rhage. The corollaries as to treatment drawn 
from these facts will be subsequently considered. 
I am anxious, however, here to direct attention 
to Nature's mechanism, because I believe there is 
no part of labor about the management of which 
erroneous views are more prevalent than that of 
this stage, and none in which they are more apt 
to lead to serious consequences ; and unless the 
mode in which Nature effects the expulsion of 
the placenta and prevents hemorrhage is thor- 
oughly understood, we shall certainly fail in assisting her in a proper 
manner. In the large proportion of cases, when left entirely to theni- 



Fig. 100. 




Mode in which the pla- 
centa is naturally expelled. 
(After Duncan.) 



1 Berry Hart : " Sectional Anatomy of Labor." Edin. Med. Journ., November, 1SS7. 



THE PHENO M E N A P L A 15 () R . 277 

selves, the placenta would be retained, it not in the uterus at any rate 
in the vagina, for a considerable tim< — possibly for several hours; 
and such delay would very unnecessarily tire the patience of the prac- 
titioner and be prejudicial to the patient. It is, therefore, our duty 
in the majority of cases to promote the expulsion of the after-birth ; 
and when this is properly and scientifically done, we increase rather 
than diminish the patient's safety and comfort. Hut in order to do 
this we must assisl Nature, and not act in opposition to her method, 
as is so often the ease. 

After-pains. — When once the placenta is expelled the uterus con- 
tracts still more firmly, and in a typical case is felt just within the 
pelvic brim, hard and firm, and about the size of a cricket-ball. Gen- 
erally for several hours, or even for one or two days, it occasionally 
relaxes and contracts, and these contractions gives rise to the " after- 
pains" from which women often suffer much. The object of these 
pains is no doubt to expel any coagula that may remain in the uterus, 
and, therefore, however unpleasant they may be to the patient, they 
must be considered, unless very excessive, to be salutary rather than 
otherwise. 

Duration of Labor. — The length of labor varies extremely in 
different cases, and it is quite impossible to lay down any definite rules 
with regard to it. Subject to exceptions, labor is longer in prirnipara? 
than in multipara?, on account of the greater resistance of the soft parts 
to the former, especially of the structures about the vagina and vulva. 
It is also generally stated that the difficulty of labor increases with the 
age of the patient, and that in elderly primipara? it is likely to be 
unusually tedious, from rigidity of the soft parts. It is very doubtful 
if this opinion has any real basis, and in such cases the practitioner 
often finds himself agreeably disappointed in the result. Mr. Roper, 1 
indeed, argues that the wasting of the tissues which occurs after forty 
years of age diminishes their resistance, and that first labors after that 
age are easier, as a rule, than in early life. The habits and mode of 
life of patients have no doubt a considerable influence on the duration 
of labor, but we are not in possession of any very reliable facts with 
regard to this subject. It is reasonable to suppose that the tissues of 
large, muscular, strongly-developed women will offer more resistance 
than those of slighter build. On the other hand, women of the latter 
class, especially in the upper ranks of life, more often develop nervous 
susceptibilities, which may be expected to influence the length of their 
labors. The average duration of labor, calculated from a large number 
of cases, is from eight to ten hours ; even in primipara?, however, it is 
constantly terminated in one or two hours irom its commencement, 
and may be extended to twenty-four hours without any symptoms of 
urgency arising. In multipara?, it is frequently over in even a shorter 
time. Indications calling for interference may arise at any time during 
the progress of labor, independently of its length. The proportion 
between the length of the first and second stages also varies consider- 
ably. The first stage is generally the longest, and it is stated by 

i Obst. Trans., 188G, vol. vii. p. 51. 



278 - LABOR. 

Cazeaux to be normally about twice the length of the second. This is 
probably under the mark, and I believe Joulin to be nearer the truth 
in stating that the first stage should be to the second as four or five to 
one, rather than as two to one. Often when the first stage has been 
very prolonged, the second is terminated rapidly. 

The practitioner is constantly asked as to the probable length of 
labor, and the uncertainty of this should always lead him to give a most 
guarded opinion. Even when labor is progressiug apparently in the most 
satisfactory manner the pains frequently die away, and delivery may 
be delayed for many hours. In the first stage a cervix that is appa- 
rently rigid and unyielding may rapidly and unexpectedly dilate, aud 
delivery soon follow. In either case, if the practitioner has committed 
himself to a positive opinion he is apt to incur blame, and it is far 
better always to be extremely cautious in our predictions on this point. 

Period of the Day at which Labor Occurs. — A somewhat larger 
proportion of deliveries occur in the early hours of the morning than 
at other times. Thus West 1 found that out of 2019 deliveries, 780 
took place from 11 p.m. to 7 a.m., 662 from 7 a.m. to 3 p.m., and 577 
from 3 p.m. to 11 p.m. 



CHAPTEE II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of the Subject. — It is quite impossible to over-esti- 
mate the importance of thoroughly understanding the mechanism of 
the passage of the foetus through the pelvis. This dominates the whole 
scientific practice of midwifery, and the practitioner cannot acquire 
more than a merely empirical knowledge, such as may be possessed 
by any uneducated midwife, or conduct the more difficult cases requir- 
ing operative interference, with safety to the patient or satisfaction to 
himself, unless he thoroughly masters the subject. 

In treating of the physiological phenomena of labor it was assumed 
that we had to do with an ordinary case of head presentation, the 
description being applicable, with slight variations, to presentations of 
other parts of the foetus. So in discussing the mechanical phenomena 
of delivery, I shall describe more in detail the mechanism of head pre- 
sentations, reserving any account of the mechanism of other presenta- 
tions until they are separately studied. Head presentation is so much 
more frequent than that of any other part — amounting to 95 per cent, 
of all cases — that this mode of studying the subject is fully justified ; 
and, when once the student has mastered the phenomena of delivery 

1 Amer. Med. Journ., 1854. 



DELIVERY IN HEAD PRESENTATIONS. 279 

in head presentations, he will have little difficulty in understanding 
the mechanism c>l' labor when other parts of the foetus present, based, 
as it always is, on the same general plan. 

Mode of Recognizing- the Position of the Head by its Sutures 
and Fontanelles. — In entering on this study we come to appreciate 
the importance of the sutures and fontanelles in enabling us to detect 
the position of the foetal head, and to watch its progress through the 
pelvis; and unless the (actus ervditus by which these can he dis- 
tinguished from each other has been acquired, the practitioner will be 
unable to satisfy himself of the exact progress of the labor. Nor is 
this always easy. Indeed, it requires considerable experience and 
practice before it is possible to make out the position of the head with 
absolute certainty; but this knowledge should always be aimed at, and 
the student w ill never regret the time and trouble he spends in ac- 
quiring it. 

At the commencement of labor the long diameter of the head lies in 
almost any diameter of the pelvic brim, except in the antero-posterior, 
where there is not space for it. In the large majority of cases, how- 
ever, it enters the pelvis in one or other of the oblique diameters, or 
in one between the oblique and transverse ; but until it has fairly 
passed through the brim, it more frequently lies directly in the trans- 
verse diameter than has been generally supposed. Hence obstetricians 
are in the habit of describing the head as lying in four positions 
according to the parts of the pelvis to which the occiput points ; the 
first and third positions being those in which the long diameter of the 
head occupies the right oblique diameter of the pelvis, the second and 
fourth those in which it lies in the left oblique. Many subdivisions 
of these positions have been made, which only complicate the subject, 
and render it more difficult to understand. 

Four Positions Described. — The positions, then, of the foetal head 
after it has entered the brim, which it is of importance to be able to 
distinguish in practice, are : 

First (left occipito-anterior, occipito-lccva anterior, o.l.a.). The occiput 
points to the left foramen ovale, the sinciput to the right sacro-iliac 
svnchondrosis, and the long diameter of the head lies in the right 
oblique diameter of the pelvis. 

Second (right occipitoanterior, occipito-dextra anterior, o.d.a.). The 
occiput points to the right foramen ovale, the forehead to the left 
sacro-iliac synchondrosis, and the long diameter of the head lies in the 
left oblique diameter of the pelvis. 

Third (right occipito-posterior, occipito-dextra posterior, o.d.p.). The 
occiput points to the right sacro-iliac synchondrosis, the forehead to the 
left foramen ovale, and the long diameter of the head lies in the right 
oblique diameter of the pelvis. The position is the reverse of the first. 

Fourth (left occipito-posterior, occipito-lceva posteriory o.l.p.). The 
occiput points to the left sacro-iliac synchondrosis, the forehead to the 
right foramen ovale, and the long diameter of the head lies in the left 
oblique diameter of the pelvis. The position is the reverse of the second. 

The relative frequency of these positions has long been, and still is, 
a matter of discussion among obstetricians. According to Xaegele, to 



280 



LABOR. 



whose classical essay we owe the greater part of our knowledge of the 
subject, the head lies in the right oblique diameter in 99 per cent, of 
all cases. More recent researches have thrown some doubt on the 
accuracy of these figures, and many modern obstetricians believe that 
the second (o.d.a.) position, which Naegele believed only to be ob- 
served as a Transitional stage in the natural progress of the third 
(o.d.p.) position, is much more common than he supposed. This 
question will be more fully discussed when we treat of the mechanism 
of occipito-posterior delivery, and, in the meantime, it may serve to 
show the discrepancy which exists in the opinions of modern writers, 
if we append the following table of the relative frequency of the 
various positions, 1 copied from Leishman's work : 



Not 
classified. 



Naegele 
Naegele, Jr. 
Simpson and Barry 
Dubois . 
Murphy 
Swayne 



First 


Second 


Third 


Fourth 


position 


position 


position 


position j 


(O.L.A.) 


(O.D.A.) 


(O.D.P ) 


(O.L.P) 


70.00 




29.00 




64.64 




32.88 




76.45 


0.29 


22.68 


0.58 


70.83 


2.87 


25.66 


0.62 


63.23 


16.18 


16.18 


4.42 


86.36 


9.79 


1.04 


2.8 



1.00 

2.47 



Here it will be seen that all obstetricians are agreed as to the 
immensely greater frequency of the first (o.l.a.) position — the only 
point at issue being the relative frequency of the second (o.d.a.) and 
third (o.d.p.). 

Various explanations have been given of the greater frequency with 
which the head lies in the right oblique diameter. By some it is re- 
ferred to the natural tendency of the back of the foetus, as shown by 
the experimental researches of Honing and other writers, to be directed, 
in consequence of gravitation, forward and to the left side of the 
mother in the erect attitude, and backward and to her right side in 
the recumbent. The explanation given by Simpson was that the head 
lay in the right oblique diameter in consequence of the measurement 
of the left oblique being more or less lessened by the presence of the 
rectum. When the rectum is collapsed, indeed, the narrowing of the 
diameter is slight ; but it is so often distended by fecal matter — some- 
times, when constipation exists, to a very great extent — that it may 
readily have a very important influence in determining the position of 
the foetal head. 

In describing the mechanism of delivery, it will be well for us to 
concentrate our attention on the first (o.L.A.), or most common, posi- 
tion, dwelling subsequently more briefly on the differences between it 
and the less common ones. 

Description of the First Position. — In this position, when the 
head commences to descend, the occiput lies in the brim pointing to 
the left ilio-pectineal eminence, the forehead is directed to the right 
sacro-iliac synchondrosis, and the sagittal runs obliquely across the 
pelvis in the right oblique diameter. The back of the child is turned 
toward the left side of the mother's abdomen, the right shoulder to her 



1 Irishman's System of Midwifery, p. 341. 



DELIVERY IN BEAD PRESENTATIONS. 



281 



right Bide, the lefl to Iter left side ( Fig. L01). [fa vaginal examination 
be new made (the patienl lying in the ordinary obstetric position ), and 
the os be sufficiently open, the finger will impinge upon the protuber- 
ance of the right parietal bone, which is described as the " presenting 
part," a term which has received various definitions, the best of which 
is probably that adopted by Tyler Smith, viz., "that portion of tin 
foetal head felt most prominently within the circle of the os uteri, the 
vagina, and the ostium vaginae, in the successive stages of labor." If 
the tip of the examining finger ho passed slightly upward, it will feel 
the sagittal suture running obliquely across the pelvis, and, if this be 
traced downward and to the left, it will come upon the triangular poste- 
rior fontauelle, with the lanibdoidal sutures diverging from it. If the 

Fig. 101. 




Attitude of child in first position (o.l.a.). (After Hodge.) 



finger could be passed sufficiently high in the opposite direction, 
upward and to the right, it would come upon the large anterior fonta- 
nels ; but at this time that is too high up to be within reach. The 
chin is slightly flexed upon the sternum, this flexion, as we shall 
presently see, being greatly increased as the head begins to descend. 

The head, at the commencement of labor, generally lies within the 
pelvic brim, especially in primiparaa. In multiparse, owing to the 
relaxation of the abdominal parietes, the uterus is apt to fall somewhat 
forward, and the head consequently is more entirely above the brim, 
but is pushed within it as soon as labor actually commences. 

Xaegele — and his description has been adopted by most subsequent 
writers — describes the head, at this period, as lying obliquely in rela- 
tion to the brim, the right parietal bone, on which the examining finger 
impinges, being supposed by him to be much lower than the left. The 
accuracy of this view has, of late years, been contested, and it is now 
pretty generally admitted that this obliquity does not exist, and that 



282 LABOR. 

the head enters the brim of the pelvis with both parietal bones on the 
same level, and with its bi-parietal diameter parallel to the plane of 
the inlet (Fig. 102). ISaegele's view was adopted, partly because the 
finger always felt the right parietal protuberance lowest, and partly 
because it was at that point that the " caput succedaneum" or swelling 
observed on the head after delivery, was always formed. Both argu- 
ments are, however, fallacious ; for the right parietal bone is the part 
which would naturally be felt lowest, on account of the oblique posi- 
tion of the pelvis to the trunk ; while, with regard to the caput suc- 
cedaneum, it has been conclusively proved by Duncan that it does not 
form on the point most exposed to pressure, as Naegele assumed, but 
on the part of the head where there is least pressure — that is, the part 
lying over the axis of the vaginal canal. 

Fig. 102. 




First position (o.l.a.) : Movement of flexion. 

Division of Mechanical Movements into Stages. — In tracing 
the progress of the head from the position just described, obstetricians 
have been in the habit of dividing the movements it undergoes into 
various stages, which are convenient for the purpose of facilitating 
description. It must be borne in mind that these are not evident and 
distinct stages, which can always be made out in practice, but that 
they run insensibly into one another, and often occur simultaneously, 
or nearly so, in rapid labor. They may be described as : 1. Flexion. 
2. First movement of descent. 3. Levelling or adjusting movement. 
4. Hotation. 5. Second movement of descent and extension. 6. External 
rotation. 

1. Flexion. The first movement of the head consists of a rotation 
on its bi-parietal diameter, by which the chin of the child becomes 
bent on the sternum, and the occiput descends lower than the forehead. 
By this there is a clear gain of at least a half-inch, for the occipito- 
bregmatic diameter (3 J inches) becomes substituted for the occipito- 
frontal (4J inches). (Fig. 102.) 



DELIVERY IN HEAD PRESENTATIONS. 283 



11 



The movement is mos1 marked when the pelvis is narrow, and i 
some cases of pelvic deformity it lakes place to an extreme deg] 
while, in unusually Large and roomy pelves, it occurs to a very slight 
extent, ^v not at all. The reason of this flexion is twofold. Solayres 

and the majority of obstetricians explain it by saying that the expul- 
sive 1 force is communicated to the head through the vertebral column, 
and inasmuch as the head is articulated much nearer the occiput than 
the sinciput, the resistance being equal, the former must be pushed 
down. This is, doubtless, the correct explanation of the flexion after 
the membranes are ruptured; but, before that happens, the ovum is 
practically a bag of water, which is equally compressed at all points 
by the uterine contraction, and is pushed downward through the os 
en masse, the expulsive force not being transmitted through the ver- 
tebral column at all. Under snch circumstances flexion is probably 
effected in the following way : the head being articulated nearer the 
occiput than the forehead, and being equally pressed upon from below 

Fig. 103. 




First position^] (o.l.a.) : Occiput in the cavity of the pelvis. (After Hodge.) 



by the resisting structures, the pressure is more effectual on the fore- 
head — consequently that is forced upward, and the occiput descends. 
This explanation Avould also hold good after the rupture of the mem- 
branes, and probably both causes assist in effecting the movement. 

2 and 3. Descent and levelling movement. The movements of descent 
and levelling may be described together. As soon as the head is liber- 
ated from the os uteri, it descends pretty rapidly through the pelvis, 
until the occiput reaches a point nearly opposite the lower part of the 
foramen ovale (Fig. 103), and the sinciput is opposite the second bone 
of the sacrum. A levelling movement now occurs, the anterior fonta- 
nelle comes to be more easily within reach, more on a level with the 
posterior, and the chin is no longer so much flexed on the sternum. 
This change is due to the fact that the anterior end of the ovoid 
experiences greater resistance than the posterior, and as soon as this 
resistance counterbalances and exceeds that applied to the latter, the 
sinciput must descend. The right side of the head also descends more 
than the left from a similar cause, so that the head becomes, as it were, 
slightly flexed on the right shoulder. This obliquity of the head on 
its transverse diameter in the lower part of the pelvis has been denied 

p This represents the second position (o.d.a.).— Ed.1 



284 LABOR. 

by Kiineke, 1 who maintains that the head passes through the entire 
pelvis in the same position as it enters the brim ; that is, with both 
parietal bones on a level, so that the point of intersection of the trans- 
verse and antero-posterior diameters of the pelvis would correspond 
with the sagittal suture. There is, however, good reason to believe 
that in the lower half of the pelvic cavity the head is not truly 
synclitic, as Kiineke describes, but that the right parietal bone is on 
a somewhat lower level than the left. 

4. Rotation. The movement of rotation is very important. By it 
the long diameter of the head is changed from the oblique diameter 
of the pelvic cavity to the antero-posterior diameter of the outlet 
(Fig, 104), oi" to a diameter nearly corresponding to it, so that the 

Fig. 104. 




First position (o.l.a.) : Occiput at outlet of the pelvis. (After Hodge.) 

long diameter of the head is brought into relation with the longest 
diameter of the pelvic outlet. This alteration almost always takes 
place, and may be readily observed by the accoucheur who carefully 
watches the progress of labor. Various explanations have been given 
of its causes. The one most generally adopted is, that it is due to the 
projection inward of the ischial spines, which narrow the transverse 
diameter of the pelvic outlet. As the pains force the occiput down- 
ward, its rotation backward is prevented by the projection of the left 
ischial spine, while its rotation forward is favored by the smooth 
bevelled surface of the ascending ramus of the ischium. Similarly 
the ischial spine on the opposite side prevents the rotation forward of 
the forehead, which is guided backward to the cavity of the sacrum 
by the smooth surface of the sacro-ischiatic ligaments. These arrange- 
ments, therefore, give a screw-like form to the interior of the pelvis ; 
and as the pains force the head downward they are effectual in im- 
parting to it the rotatory movement which is of such importance in 
adapting it to the longest measurement of the outlet. 

By most of the German obstetricians the influence of the ischial 
spines and of the smooth pelvic planes in producing rotation is not 
admitted. They rather refer the change of direction to the increased 
resistance the head meets from the posterior wall of the pelvis, and 
from the perineal structures. Whichever part of the head first meets 
this resistance, which is much greater than that of the anterior part of 
the pelvis, must necessarily be pressed forward ; and as, in the large 

1 Die vier Factoren der Geburt, Berlin, 1869. 



DELIVERY IX BEAD PRESENTATIONS. 286 

majority of cases, the posterior fontanelle descends first, it i- thus 
pressed forward until rotation is effected. This view has the advan- 
tage of accounting equally well for the rotation in occipito-posterior 
as in occipi to -anterior positions, the former of which, on the more 
ordinarily received theory, are uot quite satisfactorily explicable. It 
:i«»t follow that the smooth surfaces of the pelvic plane- are 
without influence in favoring the rotation. On the contrary, they 
doubtless greatly facilitate it ; and it is probable thai both these 
icies operate in producing anterior rotation of the occiput. 

In some rare cases the head escapes rotation and reaches the perineum 
still lying in the oblique diameter. Even here, however, rotation is 
generally effected, often suddenly, just a- the head i- about to pass the 
vulva, and it is very rarely expelled in the oblique position. The 
movement at this stage may be explained by the perineum, which is 
attached at its sides, and grooved in its centre; to the hollow so formed 
the l«>n^' diameter of the head accommodates it-elf. and is thus rotated 
into the antero-posterior diameter of the outlet. 

o. Extension. By the process just described the face is turned back 
into the hollow of the sacrum : but the head does not lie absolutely in 
the antero-posterior diameter of the pelvic outlet, but rather in one 
between it and the oblique. The occiput is still forced down by the 
pains, and, iu consequence of its altered position, is enabled to pass 
between the rami of the pubis, and advances until its further d< - 
is checked by the nape of the ueck, which is pressed under and against 
the arch of the pubes. By this means the occiput is fixed, and, the 
pains continuing, the uterine force uo longer acts on the occiput, but 
ou the anterior part of the head, which is now pushed down and 

Fig. 105. 




First position (o.l.a.) : head delivered. (After Hodge.) 

separated from the sternum. This constitutes extension. As the head 
uds, the soft structures of the periueum are stretched, and the 
coccyx pushed back so as to enlarge the outlet. The pains continue to 
distend the perineum more and more, the head advancing and receding 
with each pain. As the forehead descends, the sub-occipito-bregmatic, 
the snb-occipito- frontal, and the sub-occipito-mental diameters succes- 
sively present ; the occiput turns more and more upward in front of 
the pubes (Fig. 105), and, at last, the face sweeps over the perineum 
and is born. 

The mechanical cause of this movement may be readily explained. 



286 



LABOR. 



As soon as the occiput has passed under the arch of the pubes, and is 
no longer resisted by the anterior pelvic walls, the head is subjected to 
the action of two forces : that of the uterine pressure acting downward 
and backward ; and that of the resistance of the posterior walls of the 
pelvis and the soft parts acting almost directly forward. The necessary 
result is that the head is pushed in a direction intermediate between 
these two opposing forces — that is, downward and forward in the axis 
of the pelvic outlet. 

In addition to the slight obliquity which exists as regards the direct 
relation of the long diameter of the head to the antero-posterior 
diameter of the outlet at the moment of its expulsion, the head also lies 
somewhat obliquely in relation to its own transverse diameter, so that, in 
the majority of cases, the right parietal bone is expelled before the left. 

6. External rotation. Shortly after the head is expelled, as soon as 
renewed uterine action commences, it may be observed to make a 
distinct rotatory movement, the occiput turning to the left thigh of the 

Fig. 106. 




External rotation of head in first position (o.l.a.). (After Hodge.) 



mother, and the face turning upward to the right thigh (Fig. 106). 
The reason of this is evident. When the head descends in the right 
oblique diameter the shoulders lie in the opposite or left oblique 
diameter, and, as the head rotates into the antero-posterior diameter, 
they are necessarily placed more nearly in the transverse. As soon as 
the head is expelled the shoulders are subjected to the same uterine 
force and pelvic resistance as the head has just been, and they are acted 
on in precisely the same way. Consequently they too rotate, but in 
the opposite direction, into the antero-posterior diameter of the outlet, 
or nearly so, just as the head did, and as they do so they necessarily 
carry the head with them, and cause its external rotation. 

The two shoulders are soon expelled, the left shoulder generally the 
first, sweeping over the perineum in the same manner as the face. 
This is, however, not always the case, and they are often expelled 
simultaneously, or the right shoulder may come first. The body soon 
follows, and the second stage of labor is completed. 



DELIVERY 1 N H E A 1) V R K S E X T A T I 



287 



Second Position. — [n the second position (o.d.a.) the long diam- 
»f tin' head lies in the hit oblique diameter of the pelvis. < >n 
making a vaginal examination, in the ordinary obstetric position, the 
. passing upward and to the right, feels the small posterior fonta- 
nelle; downward and to the left, it feels the anterior. The sagittal 
suture lies obliquely across the pelvis in the left oblique diameter. 
The description of the mechanism of delivery i- precisely the same as 
in the Grst position (o.l.a.), substituting the word left for right. Thus 
the finger impi _ s a the left parietal bone, the occiput turns from 
right to left during rotation. After the birth of the head the occiput 
turn- to the right thigh of the mother, the face to the left thigh. 

Third, or Right Occipito-sacro-iliac Position. — In the third posi- 
tion (o. D. P.) the head enters the pelvic brim with the occiput directed 
backward to the right sacro-iliac synchondrosis, and the sinciput for- 
ward to the left foramen ovale (Fig. 107). The posterior fontanelle is 



Fig. 107. 




Third position <o.d.p.) of occiput at brim of pelvis. 



directed backward, the anterior fontanelle forward, while the examin- 
ing ringer impinges on the left parietal bone. The mechanism of 
delivery in these cases is of much interest. In the large majority of 

s s, during the progress of delivery the occiput rotates forward along 
the right side of the pelvis, until it comes to lie almost in the antero- 

- rior diameter of the outlet, and passes under the pubic arch, the 
forehead passing over the perineum. It will be seen that during part 
of this extensive rotation the head must lie in the second position 
(6.D.A.), and the case terminates just as if it had been in the second 
position (o.d.a.) from the commencement of labor. 

Manner in -which the Occiput is Rotated Forward. — How i- it 
that this rotation is effected, and that the sinciput, occupying the posi- 
tion of the occiput in the first position (Vi.l.a.i. should not be rotated 
forward to the pubes as that i- ? This, no doubt, may be explained by 
the fact that the uterine force transmitted through the vertebral column 



288 LABOR. 

causes the occiput to descend lower than the sinciput, so that in most 
cases, in making a vaginal examination, the posterior fontanelle can be 
readily felt, while the anterior is high up and out of reach. The head 
is, therefore, extremely flexed, and so descends into the pelvic cavity, 
until the occiput, being now below the right ischial spine, experiences 
the resistance of the pelvic floor, opposite the right sacro-ischiatic liga- 
ment, by which it is directed forward. The forehead is, at this time, 
supposing flexion to be marked, too high to be influenced by the 
anterior pelvic plane. Pressure continuing, the occiput rotates for- 
ward, the forehead passes around the left side of the pelvis, and labor 
is terminated as in the second position (o.d.a.). 

The period of labor at which rotation takes place varies. In the 
majority of cases it does not occur until the head is on the floor of the 
pelvis, for it is then that resistance is most felt ; but the greater the 
resistance, the sooner will rotation be produced. Hence it is more 
likely to occur early, when the head is large and the pelvis compara- 
tively small. 

The facility with which this movement is effected obviously depends 
upon the complete flexion of the chin on the sternum, by which the 
anterior fontanelle is so elevated that its rotation backward is not resisted 
by the inward projection of the left ischial spine, and the occiput is 
correspondingly depressed. If, however, this flexion is not complete, 
and the anterior fontanelle is so low as to be readily within reach of 
the finger, considerable difficulty is likely to be experienced. In many 
such cases rotation is still eventually effected, but in others it is not; and 
the labor is then terminated with the face to the pubes, but at the ex- 
pense of considerable delay and difficulty. According to Dr. Uvedale 
West, of Alford, who devoted much careful study to the subject, this 
termination occurs in about 4 per cent, of occipito-posterior positions. 
When it is about to happen the anterior fontanelle may be felt very 
low down, and sometimes even the forehead and superciliary ridges. 
The uterine force pushes down the occiput, the sinciput being fixed 
behind the pubes, which it obviously cannot pass under, as does the 
occiput in the first position. The sinciput, therefore, becomes more 
flexed and pushed upward, while the resistance of the pelvic floor 
directs the occiput forward. The perineum now becomes enormously 
distended by the back part of the head, and is in great danger of 
laceration. The occiput is eventually, but not without much difficulty, 
expelled. A process of extension now occurs, the nape of the neck 
being fixed, as it were, against the centre of the perineum, the expel- 
ling force now acting on the forehead, and producing rotation of the 
head on its transverse axis. The forehead and face are thus protruded, 
and the body follows without difficulty. 

It is said that, in a few exceptional cases, where the anterior fontanelle 
is much depressed, the labor may terminate by the conversion of the 
presentation into one of the face, the head rotating on its transverse 
axis, the forehead passing to the posterior part of the pelvis, and the 
chin emerging under the pubes. It is obvious, however, that this 
change can only occur when the head is unusually small, and it must 
of necessity be extremely rare. 



DKl-lVKRY IN H E AD P K E S E N T A TI N S . 



»JSil 



Reference has already beeu made to Naegele's views as to the rarity 

of the second position (o.n..O, and to his Opinion that cases in which 
the occiput Mas found to point to the right foramen ovale were only 
transitional stages in the rotation of occipito-posterior positions. Such 
an assumption, however, is unwarrantable, unless the case has been 
watched from the very commencement of labor. Many perfectly 
qualified observers have arrived at the conclusion that second posi- 
tions (o.d.a.) are far more common than Naegele supposed; and in 
the table already quoted (page 280) it will be seen that while Murphy 
estimates the second (o.D.A.) and third (o.D.P.) as being equally fre- 
quent, Swayne believes the second (o.d.a.) to be much more common 
than the third (o.d.p.). It is probable that the weight of Naegele's 
authority has induced many observers to classify second (o.D.A.) posi- 
tions as third (o.d.p.) positions iu which partial rotation has already 
been accomplished. My own experience would certainly lead me to 
think that second (o.d.a.) positions are very far from uncommon. The 
question, however, must be considered to be in abeyance, until further 
observations by competent authorities enable us to decide it conclu- 
sively. 

Fourth, or Left Occipito-sacro-iliac Position. — The fourth posi- 
tion (o.l.p.) is just as much the reverse of the second as the third is of 
the first. The occiput points to the left (Fig. 108) sacro-iliac syn- 
chondrosis, and the finger impinges on the right parietal bone. The 
mechanism is precisely the same as in the third position (o.d.p.), the 
rotation taking place from left to right. 

Fig. 108. 




Fourth position (o.l.p.) of occiput at pelvic brim. 



Formation of the Caput Succedaneum. — The formation of the 
caput succedaneum has been already alluded to. This term is applied 
to the oedematous swelling which forms on the head, and is produced 
by effusion from the obstruction of the venous circulation caused by 
the pressure to which the head is subjected. It follows that the size 
of the swelling is in direct proportion to the length of the labor. In 
rapid deliveries, in which the head is forced through the pelvis quickly, 
it is scarcely, if at all, developed ; while after protracted labor it is 
large and distiuct, and may obscure the diagnosis of the position, by 

19 



290 LABOR. 

preventing the sutures and fontanelles being felt. Its situation varies 
according to the position of the head : thus, in the first (o.l.a.) and 
fourth (o.l.p.) positions it forms on the right parietal bone, in the 
second (o.d.a.) and third (o.d.p.) on the left ; and we may therefore 
verify, by inspection of its site, the accuracy of our diagnosis. 

An ordinary mistake which has been made by obstetricians is to 
regard the caput succedaneum as formed at the point where the head 
has been most subjected to pressure ; while, in fact, it forms on that 
part which is most unsupported by the maternal structures, and where 
the swelling may consequently most readily occur. Therefore, in the 
early stages of the labor, it always forms on the part of the head which 
lies in the circle of the os uteri ; while in subsequent stages, it forms 
on that which lies in the axis of the vaginal canal, and eventually is 
most prominent on the part that is first expelled from the vulva. 

Alteration in the Shape of the Head from Moulding". — A few 
words may be said as to the alteration in the form of the foetal head 
which occurs in tedious labors, and results from the moulding which 
it has undergone in its passage through the pelvis. The smaller the 
pelvis, and the greater the pressure applied to the head during delivery, 
the more marked this is. The result is, that in vertex presentations 
the occipito-mental and occipito-frontal diameters are elongated to the 
extent of an inch, or even more, while the transverse diameters are 
lessened, from compression of the parietal bones. This moulding is 
of unquestionable value in facilitating the birth of the child. The 
amount of apparent deformity is very considerable, and may even give 
rise to some anxiety. It is well to remember, therefore, that it is 
always transient, and that in a few hours, or days at most, the elas- 
ticity of the soft cranial bones causes them to resume their natural 
form. The caput succedaneum also disappears rapidly ; therefore no 
amount of deformity from either of these causes need give rise to 
anxiety, or call for any treatment. 



CHAPTER III 

MANAGEMENT OF NATURAL LABOR. 

Although labor is a strictly physiological function, and in a large 
majority of cases might, no doubt, be safely accomplished without 
assistance from the accoucheur, still medical aid, properly given, is 
always of value in facilitating the process, and is often absolutely 
essential for the safety of the mother and child. 

Preparatory Treatment. — The management of the pregnant woman 
before delivery is a point which should always receive the attention of 
the medical attendant, since it is of consequence that the labor should 
come on when she is in as good a state of health as possible. For this 



MANAGEMENT OV NATURAL LABOR. 291 

purpose ordinary hygienic precautions should uever be neglected in 
the Latter months of gestation. The patient should take regular and 
gentle exercise', short of fatigue, and if the weather permit, should 
spend as much of her time as possible in the open air. Hot rooms, 

late hours, and excitement of all kinds should he strictly avoided. 
The diet should he simple, nutritious, and unstimulating. The state 
of the bowels should he particularly attended to. During the lew 
days preceding labor the descent of the uterus often causes pressure on 
the rectum, and prevents its evacuation. Hence it is customary to 
prescribe occasional gentle aperients, such as small doses of castor oil, 
for a few days before the expected period of delivery. Some caution, 
however, is necessary, as it is certainly not very uncommon for labor to 
be determined rather sooner than was anticipated, in consequence of 
the irritation of too large a purgative dose. The state of the bowels 
should always be inquired into at the commencement of labor, and, if 
there be any reason to suspect that they are loaded, a copious enema 
should be administered. This is always a proper precaution to take, 
for a loaded rectum is a common cause of irregular and ineffective 
uterine action ; and even when it does not produce this result, the escape 
of the feces, in consequence of pressure on the bowel during the propul- 
sive stage, is always disagreeable both to patient and practitioner. 

The dress of the patient during" pregnancy may be here adverted 
to; for much discomfort may arise, and the satisfactory progress of 
labor may even be interfered with, from errors in this respect. 

After the uterus has risen out of the pelvis the ordinary corset which 
most women wear is apt to produce very injurious pressure; still more 
so when attempts are made to conceal the increased size by tight lacing. 
After the fourth or fifth month, therefore, the comfort of the patient 
is much increased by wearing a specially constructed pair of stays with 
elastic let into the sides and front, so that they accommodate them- 
selves to the gradual increase of the figure. Such are made by all 
stay-makers, and should be worn whenever the circumstances of the 
patient permit. Failing this, it is better to avoid the use of the corset 
altogether, and to have as little pressure on the uterus as possible ; 
although many women cannot do without the support to which they 
are accustomed. To multipara?, especially if there be much laxity of 
the abdominal parietes, a well-fitting elastic abdominal belt is often a 
great comfort. This is constructed so that it can be tightened when 
the patient is walking and in the erect position, when such support 
is most required, and readily loosened when desired. 

Necessity of Attending" to the First Summons. — It is hardly 
necessary to insist on the necessity of the practitioner attending imme- 
diately to the first summons to the patient. It is true that he may 
very often be sent for long before he is actually required. But, on the 
other hand, it is quite impossible to foresee what may be the state of 
any individual case. By prompt attention he may be able 4 to rectify a 
malposition, or prevent some impending catastrophe, and thus save his 
patient from consequences of the utmost gravity. 

The practitioner should always be provided with the articles which 
he may require. The ordinary obstetric eases, containing one or two 



292 LABOR. 

bottles and a catheter, such as are sold by most instrument-makers, are 
cumbrous and useless; while "obstetric bags" are expensive luxuries 
not within the reach of all. Everyone can manufacture an excellent 
obstetric bag for himself, at a small expense, by having compartments 
for holding bottles stitched on to the sides of an ordinary leather bag, 
such as is sold for a few shillings at any portmanteau-maker's. It is 
a great comfort to have at hand all that may be required, and the bag 
should contain chloroform or other anaesthetic, antiseptics in a con- 
centrated form, 1 chloral, laudanum, the liquor ferri perchloridi of the 
Pharmacopoeia, the liquid extract of ergot, and a hypodermatic syringe, 
with bottles containing carbolized oil, ether, and a solution of ergotine 
for subcutaneous injection. If it also contain a Higginson's syringe, 
a small elastic catheter, a good pair of forceps, and one or two suture 
needles, with some silver wire or chromic gut, the practitioner is pro- 
vided against any ordinary contingency. Other articles that may be 
required, such as thread, scissors, and the like, are generally provided 
by the nurse or patient. 

Duties on First Visiting the Patient. — On arriving at the house 
the practitioner should have his visit announced to the patient, and he 
will very often find that the first effect of his presence is to arrest the 
pains that have been hitherto progressing rapidly ; thereby affording a 
very conclusive proof of the influence of mental impressions on the 
progress of labor. If the pains be not already propulsive, it is well 
that he should occupy himself at first in general inquiries from the 
attendants as to the progress of the labor, and in seeing that all the 
necessary arrangements are satisfactorily carried out, so as to allow the 
patient time to get accustomed to his presence. If he have any choice 
in the matter, he should endeavor to secure a large, airy, and well- 
ventilated apartment for the lying-in room, as far removed as possible 
from without. He may also see to the bed, which should be without 
curtains, and prepared for the labor by having a waterproof sheeting 
laid under a folded blanket or sheet, on which the patient lies. These 
receive the discharges during labor, and can be pulled from under the 
patient after delivery, so as to leave the dry clothes beneath. Among 
the lower classes, the lying-in chamber is considered a legitimate meet- 
ing-place for numerous female friends to gossip, whose conversation is 
often distressing, and is certainly injurious, to a woman in the excitable 
condition associated with labor. The medical attendant should, there- 
fore, insist on as much quiet as possible, and should allow no one in the 
room except the nurse and some one friend whose presence the patient 
may desire. The husband's presence must be left to the wishes of the 
patient. Some women like their husbands to be with them, while 
others prefer to be without them, and the medical attendant is bound 
to act in accordance with the patient's desire. 

Antiseptic Precautions. — Here it is necessary to describe the anti- 
septic precautions which should be adopted in the practice of modern 

1 Dr. Cullingworth recommends a very handy form in -which these can be carried. He has a 
box of powders prepared, each of which contains 10 grains of corrosive sublimate. 50 of tartaric 
acid, and 1 of cochineal. One of these, dissolved in a pint of water, makes a 1 : 1000 solution of 
the perchloride of mercury.— Brit. Med. Journ., October 6, 1888. 



MANAGEMENT OF NATURAL LABOR. 

midwifery. The marvellous results which have followed the intro- 
duction of antiseptic midwifery into lying-in hospitals in all parts <>f 
the world, and which have converted these institutions from hotbeds 
of disease into safer place- for delivery than the most Luxurious homes, 
form one of the most striking chapters in the history of modern medi- 
cine. These will call for more detailed notice when we come to treat 
of puerperal septicaemia. Here it will Suffice to state thai by universal 
consent it is now recognized as essential that similar care should be 
taken in private practice, and the more scrupulous the practitioner is, 
the less will be the mortality and morbidity be lias to deal with among 
his patient-. Every practitioner who is old enough to have practised 
before antiseptics were used, and who has rigorously employed them 
of late years, will gratefully recognize the comparative comfort of his 
present work. The relief from the haunting dread of septic infection, 
which was one of the bugbears of practice in days gone by, is of itself 
an unspeakable boon. It cannot, therefore, be too strongly insisted 
on that minute care in this respect should be taken, both as regards 
the practitioner and the nurse, on whom the subsecment care of the 
patient devolves. 

Strict asepsis in midwifery is, of course, impossible ; but absolute 
cleanliness in connection with labor, along with the free use of suitable 
disinfectants, will reduce to a minimum the risk of infection by germs 
from without. The first thing to be done before making a vaginal 
examination is thoroughly to scrub the hands with soap and water, 
and the nails with a hard brush. This should be insisted on as regards 
the nurse also. A basin containing a 1 : 1000 solution of perchloride 
of mercury should be placed by the side of the bed, and the hands 
should be thoroughly washed in the fluid before making a vaginal 
examination. This ablution should be repeated frequently during the 
course of the labor. It has been conclusively shown that no other 
antiseptic is so reliable, 1 and no other should be used for the hands. 
Instead of using ordinary lard or cold cream for lubricating the exam- 
ining finger, the practitioner should carry in his bag for this purpose 
some disinfecting unguent, such as carbolized or eucalyptus vaseline. 
As soon as labor is established the vulva should be thoroughly washed 
with soap and water, and then wetted with the 1 : 1000 solution and 
for this purpose cotton-wool soaked in the solution should be used. 
Sponges, so generally employed in labor, should be banished from the 
lying-in room, since it is practically impossible to keep them perfectly 
clean. 

The use of antiseptic injections before, during, and after labor is 
a point on which there is a considerable divergence of opinion. Many 
object to them altogether as necessitating unnecessary manipulations, 
which may tend to the introduction of infective germs rather than to 
their destruction. Frequent douching during labor is certainly alto- 
gether needle--, and has the drawback of washing away the lubricating 
mucous secretion of the vagina. I am myself in the habit of ordering 
a single vaginal injection of 1 : 1000 at the commencement of labor, 

1 See Boxall on " Fever in Childbed," Obst. Trans. , vol. xxxii. p. 224. 



294 LABOR. 

and no more, and to this there can be no reasonable objection. The 
use of an occasional warm irrigation after labor has always seemed to 
me to increase the comfort of the patient ; but this rather comes to be 
considered under the head of puerperal convalescence. 

Attention to Cleanliness. — The most scrupulous care as to the 
cleanliness of the lying-in room and its furniture is an important 
point to consider. The sheets and linen should be clean and fre- 
quently changed, and sanitary towels should be used to receive the 
discharges instead of napkins, which are apt to be imperfectly cleansed. 
These are points which chiefly concern the nurse, but which it is the 
duty of the practitioner to supervise. It is most important that the 
nurse should have thoroughly impressed on her the necessity of the 
antiseptic precautions Ave are discussing, since she is in contact with 
the genitals of the patient many times daily, and for many days in 
succession, while the duties of the medical attendant in this respect 
are generally at an end when the labor is over. 

Vaginal Examination. — If pains be actually present a vaginal ex- 
amination is essential, and should not be delayed. It enables us to 
ascertain whether the labor has commenced or not, and whether the 
presentation is natural or otherwise. The pains, although apparentlv 
severe, may be altogether spurious, and labor may not have actually 
commenced. It is of much importance, both for our own credit and 
comfort, that we should be able to diagnose the true character of the 
pains ; for if they be so-called " false " pains, we might wait hours in 
fruitless expectation of progress, while delivery is still far off. The 
necessity of ascertaining, therefore, the actual state of affairs need not 
further be insisted on. [We would, in this connection, particularly 
recommend to accoucheurs the caoutchouc dam and apron devised as a 
protector and conduit by Prof. Howard A. Kelly, of Baltimore, as it 
not only prevents the soiling of the bed and the undergarments of the 
patient, but will admit of a reliable measurement of the amniotic fluid 
when in excess, and of that removed from the head by tapping in 
hydrocephalus. It has been found specially useful in cases of emer- 
gency and in practice among the poor and unprepared. — Ed.] 

False pains are chiefly characterized by their irregularity, some- 
times coming on at short intervals, sometimes with many hours between 
them ; they also vary much in intensity, some being very sharp and 
painful, while others are slight and transient. In these respects they 
differ from the true pains of the first stage, which are at first slight 
and short, and gradually recur with increased force and regularity. 
The situation of the two kinds of pains also varies ; the false pains 
being chiefly situated in front, while the true pains are felt most in 
the back, and gradually shoot around toward the abdomen. Nothing 
short of a vaginal examination will enable us to clear up the diagnosis 
satisfactorily. If the labor have actually commenced, the os will be 
more or less dilated, and its edges thinned ; while with each pain the 
cervix will become rigid, and the membranes tense and prominent. 
The false pains, on the contrary, have no effect on the cervix, which 
remains flaccid and undilated ; or, if the os be sufficiently open to 
admit the tip of the finger, the membranes will not become prominent 



MANAGEMENT OF NATURAL LAHOIt. 



•J!).", 



during the contraction. Under such circumstances we may confidently 
assure the patient thai the pains arc false, and measures should be 
taken to remove the irritation which produces them. In the large 
majority of cases the cause of the spurious pains will be found to be 
sonic disordered stale of the intestinal tract ; and they will be besl 
remedied by a gentle aperient — such as castor oil, or the compound 
colocynth pill with hyoscyamus — followed by, or combined with, a 
sedative, such as twenty minims of laudanum or chlorodyne. Shortly 
after this has been administered the false pains will die away, and not 
recur until true labor commences. 

Mode of Conducting a Vaginal Examination. — For a vaginal 
examination the patient is placed by the nurse on her left side, close 



Fig. 109. 




Examination during the first stage. 



to the edge of the bed, with the legs flexed on the abdomen. The 
practitioner being seated by the edge of the bed, passes the index 
finger of the right hand, the proper antiseptic precautions having 
previously been taken, up to the vulva, and gently insinuates it into 
the orifice of the vagina, then pushes it backward in the axis of the 
vaginal outlet, and finally turns it upward and forward so as to more 
readily reach the cervix (Fig. 109). This it may not always be easy 
to do, for at the commencement of labor the cervix may be so high as 
to be reached with difficulty, or it may be directed backward so as to 
point toward the cavity of the sacrum. The exploration is often 
much facilitated by depressing the uterus from without, by the left 
hand placed on the abdomen. Our object is not only to ascertain 
the state of the cervix as to softness and dilatation, but also the 
presentation, the condition of the vagina, and the capacity of the 



296 LABOR. 

pelvis. The examination is generally commenced during a pain, at 
which time it is less depressing to the patient ; but in order to be 
satisfactory the finger must remain in the vagina until the pain is 
over, the examination being concluded in the interval between this 
pain and the next. 

In head presentations the round mass of the cranium is generallv at 
once felt through the lower part of the uterus, and then we have the 
satisfaction of being able to assure the patient that all is right. If the 
os be sufficiently dilated, we can also feel through it the occiput covered 
by the membranes. It is impossible at this time to make out the exact 
position of the head by means of the sutures and fontanelles, which are 
too high up to be within reach. Nor should any attempt be made to do 
so, for fear of prematurely rupturing the membranes. The fact that 
the head is presenting is all that we require to know at this stage of 
the labor. 

The condition of the os itself, as to rigidity and dilatation, will 
materially assist us in forming an opinion as to the progress and prob- 
able duration of the labor ; but, although the friends will certainly 
press for an opinion on this point, the cautious practitioner will be care- 
ful not to commit himself to a positive statement, which may so easily 
be falsified. It will suffice to assure the friends that everything is 
satisfactory, but that it is impossible to say with any certainty how 
rapidly, or the reverse, the case may progress. 

If the pains be not very frequent or strong, and the os not dilated 
to more than the size of a shilling, a considerable delay may be 
anticipated, and the presence of the medical attendant is useless. He 
may, therefore, safely leave the patient for an hour or more, provided 
he be within easy reach. It is needless to say that this should never 
be done unless the exact presentation be made out. If some part other 
than the head be presenting, it will probably be impossible to make it 
out until dilatation has progressed further ; and the practitioner must 
be incessantly on the watch until the nature of the case be made out, 
so as to be able to seize the most favorable moment for interference, 
should that be necessary. 

Position of Patient during- First Stage. — The position of the 
patient in the first stage is a matter of some moment. It is a decided 
advantage that she should not be then in a recumbent position on her 
side, as is usual in the second stage ; for it is of importance that the 
expulsive force should act in such a way as to favor the descent of the 
head into the pelvis, i. e., perpendicularly to the plane of its brim, and 
also that the weight of the child should operate in the same way. 
Therefore, the ordinary custom of allowing the patient to walk about, 
or to recline in a chair, is decidedly advantageous ; and it will often 
be observed that the pains are more lingering and ineffective if she lie 
in bed. If the patient be a multipara, or if the abdomen be somewhat 
pendulous, an abdominal bandage, by supporting the uterus, will 
greatly favor the progress of this stage. Keeping the patient out of 
bed has the further advantage of preventing her being unduly anxious 
for the termination of the labor ; and a little cheerful conversation 
will keep up her spirits, and obviate the mental depression which is 



MANAGEMENT OF NATURAL LABOR. 297 

bo common. Good beef-tea may be freely administered, with a little 
brandy-and-water occasionally it' the patienl be weak, and will be 
useful iii supporting her strength. 

( hrer-frequent vaginal examinations at this period should be avoided, 
for they Berve do useful purpose, and arc apt to irritate the cervix. It 
will be necessary, however, to ascertain the progress of the dilatation 
at intervals. 

When once the os is fully dilated the membranes may be artificially 
ruptured if they have not broken spontaneously, for they no longer 
serve any useful purpose, and only retard the advent of the propulsive 
stage. This can be easily done by pressing on them, when they are 
rendered tense during a pain, by some pointed instrument, such as the 
end of a hairpin, which is always at hand. In some cases, indeed, it 
is even expedient to rupture the membranes before the os is fully 
dilated. Thus it not unfrequently happens, when the amount of 
liquor amnii is at all excessive, that the os dilates to the size of a 
tive-shilling-piece or more; but, although it is perfectly soft and 
flaccid, it opens up no further until the liquor amnii is evacuated, 
when the propulsive pains rapidly complete its dilatation. Some 
experience and judgment are required in the detection of such cases, 
for if we evacuate the liquor amnii prematurely the pressure of the 
head on the cervix may produce irritation, and seriously prolong the 
labor. This manoeuvre is most likely to be useful when the pains are 
strong and the os perfectly flaccid, but when the membranes do not 
protrude through the os so as to effect further dilatation. 

It is sometimes not easy to ascertain whether the membranes are 
ruptured or not. This is most likely to be the case when the head is 
low down, and the amount of liquor amnii is so small that the pouch 
does not become prominent during the pains. A little care, however, 
will enable us, if the membranes be ruptured, to feel the rugosities of 
the scalp covered with hair, and to distinguish it from the smooth 
polished surface of the membranes. 

After the evacuation of the liquor amnii there is generally a lull in 
the progress of the labor, the pains, however, soon recurring with 
increased force and frequency, and propelling the head through the 
pelvic cavity. The change in the character of the pains is soon appre- 
ciated by the bearing-down efforts by which they are accompanied, as 
well as by their increased length and intensity. 

Position of the Patient during- the Second Stage. — It is now 
advisable that the patient be placed in bed ; and in England it is 
usual for her to lie on her left side, with her nates parallel to the edge 
of the bed, and her body lying across it. This is the established 
obstetric position in our country, and it would be useless to attempt to 
insist on any other, even if it were advisable. Although the dorsal 
position is preferred on the Continent, it is difficult to see wherein its 
advantages consist. It certainly leads to unnecessary exposure of the 
person, and it is, on the whole, less easy to reach the patient, so placed, 
for the necessary manipulations. Moreover, the dorsal position in- 
creases the risk of laceration of the perineum, by bringing the weight 
of the child's head to bear more directly upon it. Thus Schroeder 



298 LABOR. 

found that lacerations occurred in 37.6 per cent, of cases delivered on 
the back, as against 24.4 per cent, in other positions. 

The patient usually remains in bed during the whole of this stage, 
and it is customary for the nurse to tie to the foot of the bed a jack- 
towel, which is laid hold of and used as a support in making bearing- 
down efforts. If the pains be few and far between, and the patient 
finds it more comfortable to get up occasionally, there is no reason 
why she should not do so. On the contrary, as we shall subsequently 
see, in treating of lingering labor, the pains under such circumstances 
are often increased in the sitting posture in consequence of the weight 
of the child producing increased pressure on the nerves of the vagina. 

At this time vaginal examination, which should be more frequently 
repeated than in the first stage, enables us to ascertain precisely the 
position of the head, by means of the sutures and fontanelles, as well 
as to watch its progress. 

It not unfrequently happens that the head descends into the pelvis, 
even to its floor, without the os having entirely disappeared. The 
anterior lip especially is apt to get caught between the head and pubes, 
to become swollen by the pressure to which it is subjected, and thus 
to retard the progress of the labor. There can be no reasonable 
objection to attempting to prevent this cause of delay by pressing on 
the incarcerated lip during the interval of the pains, so as to push it 
above the head, and maintain it there during the pains until the head 
descends below it. This manoeuvre, if done judiciously, and without 
any undue roughness or force, is certainly not liable to be attended by 
any of the evil consequences which many obstetricians have attributed 
to it ; it is indeed a matter of common sense that the injury to the 
cervix is likely to be less if it be pushed gently out of the way than 
if it be left to be tightly jammed for hours between the presenting 
part and the bony pelvis. This mode of assistance is very different 
from the digital dilatation of a rigid cervix, which was formerly much 
practised, especially in Edinburgh, in consequence of the recommenda- 
tion of Hamilton, and which was properly objected to by the great 
majority of obstetricians. 

If the pains be producing satisfactory progress, no further inter- 
ference is required. The medical attendant should, however, see that 
the bladder is evacuated ; and if it have not been so for some hours, 
it may be necessary to draw off the urine by the catheter. \Thenever 
the labor is lengthy, he should occasionally practise auscultation, so as 
to satisfy himself that the foetal circulation is being satisfactorily 
carried on. 

The regulation of the bearing-down efforts at this time is of impor- 
tance. It is common for the nurse to urge the patient to help herself 
by straining, and it is certain that by voluntary action of this kind 
she can materially increase the action of the accessory muscles of par- 
turition. If the pains be strong, and the labor promise to be rapid, 
such voluntary exertions are not likely to be prejudicial. On the 
other hand, if the case be progressing slowly, they only unnecessarily 
fatigue the patient, and should be discouraged. AVhen the perineum 
is distended we may even find it advisable to urge the patient to cease 



MANAGEMENT OF NATURAL LABOR. 299 

all voluntary effort, and to cry out, for the express purpose of lessen- 
ing the tension to which the perineum is subjected. This is the stage 
in which anaesthesia is most serviceable, but its employment must be 
separately discussed. 

Distention of the Perineum. — As the head descends more and 
more the perineum becomes distended, and there is considerable differ- 
ence of opinion amongst accoucheurs as to the management of the case 
at this time. In most obstetric works the practitioner is advised to 
endeavor to prevent laceration by the manoeuvre that is described as 
supporting the perineum. By this is meant, laying the palm of the 
hand on the distended structures, and pressing firmly upon them 
during the acme of the pain, with the view of mechanically pre- 
venting their tearing. There can be little doubt that this, or some 
modification of it, is the practice followed by the large majority of 
practitioners. Of late years the evil effects likely to attend it have 
been specially dwelt upon by Graily Hewitt, Leishman, Goodell, and 
other writers, who maintain that by pressure exerted in this fashion 
we not only fail to prevent, but actually favor, laceration, in conse- 
quence of the pressure producing increased uterine action, just at the 
time when forcible distention of the perineum is likely to be hurtful. 
Therefore some hold that the perineum ought to be left entirely alone, 
and that the head should be allowed gradually to distend it, without 
any assistance on the part of the practitioner. 

Much error may be traced to a misconception of what is required. 
The term " supporting the perineum " conveys an unquestionably 
erroneous idea, and it is certain that no one can prevent laceration by 
mechanical support. If the term relaxation of the perineum were em- 
ployed, Ave should have a far more accurate idea of what should be 
aimed at, and, if this be borne in mind, I think it cannot be ques- 
tioned that Nature may be most usefully assisted at this stage. 

Dr. Goodell, of Philadelphia, has specially studied this subject, and 
has recommended a method the object of which is to relax the peri- 
neum. His advice is, that one or two fingers of the left hand should 
be inserted into the rectum, by which the perineum should be hooked 
up and pulled forward over the head, toward the pubes, the thumb of 
the same hand being placed on the advancing head, so as to restrain 
its progress if needful. I have adopted this plan frequently, and 
believe that it admirably answers its purpose, especially when the peri- 
neum is greatly distended, and laceration is threatened. It must be 
admitted that the insertion of the fingers into the anal orifice, in the 
manner recommended, is repugnant both to the practitioner and 
patient, and the same result can be obtained in a less unpleasant way. 
I mention it, however, to show what it is that the practitioner must 
aim at. If, when the head is distending the perineum greatly, the 
thumb and forefinger of the right hand are placed along its sides, it 
can be pushed gently forward over the head at the height of the pain, 
while the tips of the fingers may, at the same time, press upon the 
advancing vertex, so as to retard its progress if advisable (Fig. 110). 
By this means the sudden and forcible stretching of the perineal struc- 
tures is prevented, and the chance of laceration reduced to a minimum, 



300 



LABOR. 



while Nature's mode of relaxiug the tissues, by dilatation of the 
anal orifice, is favored. This is very different from the mechanical 
support that is usually recommended, and the less pressure that is 
applied directly to the perineum the better. Nor is it either needful or 
advisable to sit by the patient with the hand applied to the perineum 
for hours, as is so often practised. Time should be given for the 
gradual distention of the tissues by the alternate advance and recession 
of the head, and we need only intervene to assist relaxation when the 
stretching has reached its height, and the head is about to be expelled. 
A napkin may be interposed between the hand and the skin, for the 
purpose of cleanliness. Should the perineum be excessively tough and 
resistant, assiduous fomentation with a hot sponge may be resorted to, 
and will be of some service in promoting relaxation. 



Fig. 110. 




. '.; 



Mode of effecting relaxation of the perineum. 



Incision of the Perineum. — "When the tension is so great that 
laceration seems inevitable, it is generally recommended that a slight 
incision should be made on each side of the central raphe, with the 
view of preventing spontaneous laceration. This may no doubt be 
done with perfect safety, but I question if it is likely to be of use. 
The idea is that an incised wound is likely to heal more readily than 
a lacerated one. "When, however, a distended perineum ruptures, its 
structures are so thinned that the tear is always linear ; and, as a 
matter of fact, the edges of the tear are always as clean, and as closely 
in apposition, as if the cut had been made with a knife. Moreover, 
the laceration invariably heals perfectly, if only the edges be brought 
into contact at once with one or two sutures. I believe, therefore, that 
Goodell is right in stating that incision of the perineum is rarely, if 
ever, necessary, unless it is hardened by previous cicatrization. In 
almost all first labors the fourchette is torn, but requires no treatment 



MANAGEMENT OF NATURAL LABOR. 801 

of any kind. In some cases, do what we will, more or less Laceration 
occurs, and the perineum should always be examined after the expul- 
sion of the child, to sec if any tear has taken place. 

It' it has given way to any extent, 1 believe that it is good practice 
to insert one or two interrupted sutures of silver wire or chromic out 
at once. Immediately after delivery the sensibility of the tissues is 
deadened by the distention to which they have been subjected, and the 
Sutures can bo inserted with little or no pain. It is quite true that 
lacerations of an inch or less will generally heal perfectly well of them- 
selves; hut this is not invariably the case, while healing almost cer- 
tainly follows if the edges be brought together at once. In the severer 
forms of laceration, extending back to, or even through, the sphincter, 
the precaution is all the more necessary, and a subsequent operation of 
gravity may in this way be avoided. The sutures can be removed 
without difficulty iu a week or so, when complete adhesion has taken 
place. 

Expulsion of the Child. — The head, when expelled, should be 
received in the palm of the right hand, while the left hand is placed 
upon the abdomen to follow down the uterus as it contracts and expels 
the body. There is generally some little delay after the expulsion of 
the head, and we should now see if the cord surround the neck, and, 
if it does so, it should be drawn over the head, and, if this is not pos- 
sible, it may be tied and divided between the ligatures, The expulsion 
of the body should be left entirely to the uterine contractions. If 
there be undue delay we may endeavor to excite uterine action by fric- 
tion on the fundus, and it will rarely happen that sufficient contraction 
does not now come on. If w r e display undue haste in withdrawing 
the body, we run the risk of emptying the uterus while its tissues are 
relaxed, and so favor hemorrhage. If, however, there seems serious 
danger of the child being asphyxiated, its expulsion may be favored 
by gently passing the forefinger of each hand within the axillae, and 
using traction ; but it is only very exceptionally that such interference 
is required. 

Promotion of Uterine Contraction after the Birth of the 
Child. — As the uterus contracts, it should be carefully followed down 
through the abdominal parietes by the left hand, which should grasp 
it as the body is expelled, with the view of seeing that it is efficiently 
contracted. This is a point of vital importance in preventing hemor- 
rhage, which will presently be more especially considered. 

As soon as the child cries we may proceed to tie and separate the 
cord. For this purpose the nurse usually provides ligatures composed 
of several strands of whitey-brown thread; but tape, or any other 
suitable material, may be employed. It is important, especially if the 
cord be very thick and gelatinous, to see that it is thoroughly com- 
pressed, so that the vessels are obliterated, otherwise secondary hemor- 
rhage might occur. The cord is tied about an inch and a half from 
the child, and it is usual, though, of course, not essential, to place a 
second ligature about two inches nearer the placental extremity of the 
cord. The latter is, perhaps, of some use by retaining the blood, and 
thus increasing the size of the placenta, and favoring its more ready 



302 LABOR. 

expulsion by uterine contraction. The cord is then divided with 
scissors between the ligatures, the child wrapped up in flannel, aud 
given to the nurse, or to a bystander, to hold, while the attention of 
the practitioner is concentrated on the mother, with a view to the 
proper management of the third stage of labor. The researches of 
Budin, 1 Ribemont, 2 and others show that there is a distinct advantage 
in not tying the cord until the child has cried lustily, as the act of 
respiration tends to withdraw the placental blood, and thus increases 
the entire amount of blood in the foetus. It is said that after late 
ligature of the cord the child is more vigorous and active than when 
it is tied too early. 

The cord may, if preferred, be treated with perfect safety by lacera- 
tion. This method was first brought under my notice by the late Dr. 
Stephen, who employed it for many years, and in several hundred 
cases. The cord is twisted round the index fingers of both hands, and 
torn through, the lacerated vessels retracting without any hemorrhage. 
It is a close imitation of the method instinctively adopted by the 
lower animals, who gnaw the cord asunder, and has the advantage of 
dispensing with ligatures altogether. I have used it myself in a large 
number of cases, but prefer, on the whole, the plan usually adopted. 

Importance of Proper Management of Third Stage. — There is 
unquestionably no period of labor where skilled management is more 
important, and none in which mistakes are more frequently made. 
By proper care at this time the risk of post-partum hemorrhage is 
reduced to a minimum, the efficient contraction of the uterus is secured, 
the amount and intensity of after-pains are lessened, and the safety and 
comfort of the patient greatly promoted. Moreover, the general prac- 
tice, as to the management of this stage, is opposed to the natural 
mechanism of placental expulsion, and is far from being well adapted 
to secure the important objects which we ought to have in view. Let 
us see what is the practice usually recommended and followed, and 
then we shall be in a position to understand in what respects it is 
erroneous. For this purpose I cannot do better than copy the direc- 
tions contained in one of our most deservedly popular obstetric text- 
books, which undoubtedly expresses the usual practice in the manage- 
ment of this stage : " When the binder is applied, the patient may be 
allowed to rest a while, if there is no flooding ; after which, when the 
uterus contracts, gentle traction may be made by the funis, to ascertain 
if the placenta be detached. If so, and especially if it be in the 
vagina, it may be removed by continuing the traction steadily in the 
axis of the upper outlet at first, at the same time making pressure on 
the uterus." 3 

[In this country, for many years, the uniform teaching has been 
that the binder should not be applied until the uterus has expelled the 
placenta and become firmly contracted. Although the plan of expres- 
sion was not carried out as completely as is now taught under the Crede 
method, that of stimulating the contractions of the uterus by nianipu- 

1 Budin : Progres Medical, 1876.. torn. iv. pp. 2, 36. 

2 Archiv. de Tocologie, 1879, p.' 577. 

3 Churchill's Theory and Practice of Midwifery, p. 162. 



MA N A G K M K N T F N A T U R A L L A BO R . 303 

lation and pressure was certainly in use forty years ago. When the 
si/o and solidity of the uterus, as ascertained by the compressing hand, 
indicate 1 that the placenta has been expelled into the vagina, it Is a 

(110 



ition whothor we shall cause ii to ho forced through the vulva l»\ 



pressing down the uterus upon it, or make traction upon it by the 
anger hooking down its edge. Occasionally we find a patient who 
is very sensitive to pressure made upon her uterus after it has become 
firmly contracted; and in such a case it may ho well to depend partly 
upon traction for completing the delivery of the secundines. That it 
is possible for the uterus to expel the placenta suddenly from the vagina 
where no pressure has been made is evident from the fact that a physi- 
cian of this city, who was making traction upon the cord under the old 
method some years ago, was surprised to find the placenta shoot out 
from the vulva and dangle by the funis as he held it in his hand. In 
such a case the uterus must have been aided during a contraction by 
voluntary abdominal pressure, causing the os to descend nearly to the 
vulva. It is very evident that the uterus is subject to muscular fatigue 
and to the exhaustion of its contractile power when loug in action ; 
hence there is a greater risk of uterine atony and hemorrhage after a 
long labor than a short one, and we may expect a more complete expul- 
sion of the placenta in the latter. It is also clear, from cases in my 
own experience, that the muscular power of the uterus is by no means 
in proportion to the general strength of the woman. The power to 
assist by bearing down no doubt is, but the independent power of the 
organ itself does not appear to be. Certainly some of the most perfect 
in parturient power that have come under my care were small women 
with little general muscular force. One little woman of eighty-six 
pounds weight appeared almost to have escaped the curse pronounced 
upon Eve ; and another, still smaller, expelled a placenta from her 
vagina almost without any loss of blood. — Ed.] 

This may fairly be taken as a sufficiently accurate description of the 
practice usually followed. 1 The objections I have to make are: 1. 
That it inculcates the common error of reiving on the binder as a 
means of promoting uterine contraction, advising its application before 
the expulsion of the placenta ; while I hold that the binder should 
never be applied until after the placenta is expelled, and not even then, 
unless the uterus is perfectly and permanently contracted. 2. That it 
teaches that traction on the cord should be used as a means of with- 
drawing the placenta; whereas the uterus itself should be made to 
expel the afterbirth, and in nineteen cases out of twenty, the finger 
need never be introduced into the vagina after the birth of the child, 
nor the cord touched. This may seem an exaggerated statement to 
those who have accustomed themselves to the usual method of dealing 
with the placenta ; but I feel confident that all who have learnt the 
method of expression would testify to its accuracy. 

Expression of the Placenta: Its Object. — The cardinal point to 
bear in mind is, that the placenta should be expelled from the uterus 

1 This practice is further illustrated by the annexed diagram, contained in most obstetric works, 
which represents the accoucheur as withdrawing the placenta by traction, and which I insert as 
an illustration of what ought not to be done (Fig. 111). 



304 



LABOR, 



by a vis a tergo, not drawn out by a vis a f route. That uterine pressure 
after the birth of the child has been recommended by many English 
writers is certain, and the Dublin school especially have dwelt on its 
importance as a preventive of post-partum hemorrhage ; but the dis- 
tinct enunciation of the doctrine that the placenta should be pressed, 
and not drawn out of the uterus, we owe to Crede" and other German 
writers ; and it is only of late years that this practice has become at 
all common. Those who have not seen placental expression practised 
find it difficult to understand that, in the large majority of cases, the 
uterus may be made to expel the placenta out of the vagina ; but such 

Fig. 111. 




Usual method of removing the placenta by traction on the cord. 



is unquestionably the fact. A little practice is no doubt necessary to 
effect this satisfactorily ; but when once the knack has been learned, 
there is little difficulty likely to be experienced. 

Before describing the method of placental expression, a word of 
caution may be said against undue haste in attempting expression of 
the placenta, a mistake that is often made, and which, I believe, tends 
to increase the risk of post-partum hemorrhage. So long as we satisfy 
ourselves that the uterus is fairly contracted so as to avoid the possi- 
bility of its distention with blood, a certain delay after the birth of the 
child is useful, from its giving time for coagula to form within the 
uterine sinuses, by which their open mouths are closed up. The im- 
portance of this point has been specially dwelt upon by McClintock, 
who lays down the rule that fifteen or twenty minutes should be allowed 
to elapse after the birth of the child, before any attempt to remove the 
afterbirth is made. This is a good and safe practical rule, as it gives 
ample time for the complete detachment of the placenta and the coagu- 
lation of the blood in the uterine sinuses. 



MANAGEMENT OF NATURAL 



ABOR 



305 



During this interval the practitioner or nurse should sit by the bed- 
Bide, with the hand on the uterus to secure contraction and prevent dis- 
tention; but not kneading or forcibly compressing it. When we judge 
that a sufficient time lias elapsed, we may proceed to effeci expulsion. 

For this purpose the fundus should he grasped in the hollow of the 
left hand, the ulnar edge of the hand being well pressed down behind the 
fundus, and, when the uterus is felt to harden, strong and firm pressure 
should be made downward and backward in the axis of the pelvic brim. 
I f this manoeuvre be properly carried out, and sufficiently firm pressure 
made, in almost every ease the uterus may be made to expel the placenta 
into the bed, along with any eoagula that may be in its cavity (Fig. 



Fig. 112. 




Illustrating expression of the placenta. 



112). The uterine surface of the placenta is generally expelled first, as 
is represented in the diagram, the cord being within the membranes ; 
whereas the foetal surface, and root of the cord, are the parts which 
appear first when the placenta is removed by traction (Fig. 111). If 
we do not succeed at the first effort, which is rarely the case if extru- 
sion be not attempted too soon after the birth of the child, we may wait 
until another contraction takes place, and then reapply the pressure. 
I repeat that, after a little practice, the placenta may be entirely ex- 
pelled in this way, in nineteen cases out of twenty, without even touch- 
ing the cord, and the bugbear of retained placenta will cease to be a 
source of dread. 

Should Ave fail in causing the uterus to expel the placenta, a vaginal 
examination may be made, and, if the placenta be found lying entirely 
in the vagina, it may be carefully withdrawn. If, however, the cord 
can be traced up through the os, showing that the placenta is still 
within the uterine cavity, wc must again resort to pressure to effect its 
expulsion, and not attempt to withdraw it by traction. Such cases 
may fairly be classed as retained placenta, but they should be very 
rarely met with, and are discussed elsewhere. When they do occur 

20 



306 LABOR. 

often in the hands of the same practitioner, it is fair to conclude that 
he has not properly acquired the art of managing this stage of labor. 
Generally speaking, the placenta should be expelled within twenty 
minutes after the birth of the child ; but no doubt, in the large ma- 
jority of cases, expulsion might be effected sooner were it advisable to 
attempt it. 

Management of the Membranes. — When the mass of the placenta 
is expelled, the membranes generally still remain in the vagina, and 
they should be twisted into a rope, and very gently withdrawn, so as 
not to leave any portion behind. This is a precaution the importance 
of which I would strongly urge, for I believe that the chance of part 
of the membranes being torn off and left in utero is the oue objection 
to the method recommended. With due care, however, this accident 
may be avoided, and the risk will be lessened if the placenta is received 
into the palm of the right hand, on expression, so as to avoid any 
strain on the membranes. 

The duties of the medical attendant are not even now over. For 
at least ten minutes after the extrusion of the placenta, he should keep 
his hand on the firmly contracted uterus, gently kneading it, without 
any force, for the purpose of promotiug firm and equable contraction, 
and causiug it to throw off the coagula that may form in its cavity. 

The subsequent comfort and safety of the patient may be promoted 
by administering at this time a full dose of ergot of rye, such as a 
drachm, or more, of the liquid extract. The property possessed by 
this drug of producing tonic and persistent contraction of the uterine 
fibres, which renders it of doubtful utility as an oxytocic during labor, 
is of special value after delivery, when such contraction is precisely 
what we desire. I have Ions: been in the habit of administering the 
drug at this period, and believe it to be of great value, not only as a 
prophylactic against hemorrhage, but as a means of lessening after- 
pains. 

Examination of the Placenta. — The accoucheur should always 
satisfy himself as to the integrity of the placenta, and not be satisfied 
with the report of the nurse. It should be carefully examined in 
every case, to make sure that no portion of it, nor of the membrane, is 
left behind. It is well to re-invert the membranes, and examine the 
uterine surface of the placenta in the first instance, and then to satisfy 
oneself that the membranes, both chorion and amnion, are entire. If 
any portion is absent, it must be carefully searched for in the clots, or 
in the vagina or uterine cavitv. Should it be necessary to introduce 
the finger or hand for this purpose, even when carefully asepticized, 
the uterus should subsequently be washed out with a douche of hot 
water at 110° F., to which a few drops of creolin have been added, or 
with a solution of perchloride of mercury (1 : 2000), at the same 
temperature. 

Application of the Binder. — "When we are satisfied that the uterus 
is permanently contracted, we may apply the binder, but this should 
rarely be done until at least half an hour after the birth of the child. 
The soiled clothes should be gently withdrawn from under the patient, 
moving her as little as possible, and the binder should be, at the same 



MANAGEMENT OF NATURAL LABOR. 307 



«>\v 



time, Blipped under the body, taking care thai it is passed well be 
the hips bo as to secure a firm hold. No kind of bandage is better 
than a piece of stout jean, of sufficienl breadth to extend from the 
trochanters to the ensiform cartilage; a jack-towel or bolster slip 
answers the purpose very well. These arc preferable, at any rata at 
first, to the shaped binders that arc often used. One or two folded 
napkin- are generally placed over the uterus, bo a- to form a pad to 
keep up the pressure. Once in position, the binder is pulled tight, 
and fastened by pins. The utility of careful bandaging alter delivery 
can scarcely be doubted, although some years ago it became the fashion 
to dispense with it. It give- a comfortable support to the lax abdom- 
inal walls, keeps up a certain amount of pressure on the uterus, and 
tend- to restore the figure of the patient. After the bandage is 
applied, a warm antiseptic pad or napkin should be placed on the 
vulva, as a means of estimating the quantity of the discharge, and the 
patient may be allowed to rest. 

Examination of the Perineum. — In every case, especially in pri- 
miparae, the perineum should be visually examined. This can easily be 
done after the placenta is expelled, without distressing the patient. If 
this precaution were habitually adopted many lacerations would be 
detected, which would otherwise escape observation. 

After-Treatment . — Unless the labor has been very long and fati- 
guing, an opiate, often exhibited as a matter of routine, is [inadvisable ; 
although it may be well to leave one with the nurse, to be given if the 
patient cannot sleep, or if the after-pains be very troublesome. The 
practitioner may now leave the room, but not the house, and at least 
an hour should elapse after delivery before he takes his departure. 
Before doing so he should visit the patient, inspect the napkin to see 
that there is not too much discharge, and satisfy himself that the 
uterus is contracted, and not distended with coagula. He should also 
count the pulse, which, if the patient be progressing satisfactorily will 
found at its normal average. If, however, it be beating over 100 per 
minute, he should on no account leave, for such a rapidity of the cir- 
culation renders it extremely probable that hemorrhage is impending. 
This is a good practical rule laid down by Mcdintock in his excellent 
paper " On the Pulse in Childbed." attention to which may often save 
the patient from disastrous consequences. 

Before leaving, the practitioner should see that the room is darkened, 
all bystanders excluded, and the patient left as quiet as possible to 
recover from the shock of labor. 



308 LABOR. 



CHAPTEE IV. 

ANAESTHESIA IN LABOR. 

A few words may be said as to the use of anaesthetics during labor, 
a practice which has become so universal that no argument is required 
to establish its being a perfectly legitimate means of assuaging the suf- 
ferings of childbirth. Indeed the tendency in the present day is in 
the opposite direction ; and a common error is the administration of 
chloroform to an extent which materially interferes with the uterine 
contractions and predisposes to subsequent post-partum hemorrhage. 

Agents Employed. — Practically speaking, the only agent hitherto 
employed in this country is chloroform, although the bichloride of 
methylene, and ether, have been occasionally tried. Of late years, 
chloral has been extensively used by some ; and as I believe it to be 
an agent of very great value, I shall first indicate the circumstances 
under which it may be employed. 

Chloral. — The peculiar value of chloral in labor is, that it may be 
safely administered at a time when chloroform cannot be generally 
employed. The latter, while it annuls suffering, very frequently 
tends, in a marked degree, to diminish uterine action. This is a 
familiar' observation to all who have employed it much during labor, 
as the diminution of the force and intensity of the pains, and the con- 
sequent retardation of the labor, often oblige us to supend its inhala- 
tion, at least temporarily. Indeed, this very property of annulling 
uterine action is one of its most valuable qualities in obstetrics, as in 
certain cases of turning. For such purposes it is necessary to give it 
to the surgical extent, which we endeavor to avoid when it is used 
simply to lessen the suffering of ordinary labor. Still it is not always 
easy to limit its action in this way, and thus it very frequently does 
more than we wish. Such diminution in the intensity of uterine con- 
traction is comparatively of less consequence in the propulsive stage, 
and it is generally more than counterbalanced by the relief it affords. 
In the first stage it is otherwise, and, practically speaking, chloroform 
is generally not admissible until the head is in the pelvic cavity. 

Chloral, on the other hand, has no such relaxing effects on uterine 
contraction. It cannot, it is true, compete with chloroform in its 
power of relieving pain, but it produces a drowsy state in which the 
pain is not felt nearly so acutely as before. It is, therefore, in the 
first stage of labor, while the pains are cutting and grinding, and 
during the dilatation of the cervix, that it finds its most useful appli- 
cation. It is especially valuable in those cases, so frequently met 
with in the upper classes, in which the pains produce intolerably 
acute suffering, but with little effect on the progress of the labor. In 



A N 1ST II KS1 A IN LABOR. 309 

them the os is often thin and rigid, and the pains very frequent and 
acute, Imt little or no dilatation is effected. When the patient is brought 

under the influence of chloral, however, the pains become less frequent 
but Stronger, nervous excitement is calmed, and the dilatation of the 
Cervix often proceeds rapidly and satisfactorily. Indeed, I know of 
nothing which answers so well in eases of rigid, imdilatable cervix, 
and I believe it to be far more effective, under such circumstances, 
than any of the remedies usually employed. 

The object is to produce a somnolent condition, which shall he pro- 
tracted as long as possible. For this purpose fifteen grains of chloral 
may be administered every twenty minutes, until three doses are 
given. This generally suffices to produce the desired effect. The 
patient becomes very drowsy, dozes between the pains, and wakes up 
as each contraction commences. It may be necessary to give a fourth 
dose at a longer interval, say an hour after the third dose, to keep np 
and prolong the soporific action ; but this is seldom necessary, and I 
have rarely given more than forty to fifty grains of chloral during the 
entire progress of labor. Another advantage of this treatment is that, 
while it does not interfere with the use of chloroform in the second 
stage, it renders it necessary to give less than otherwise would be 
called for and thus its action can be more easily kept within bounds. 
On the whole, therefore, I am inclined to consider chloral a very 
valuable aid in the management of labor, and believe that it is 
destined to be much more extensively used than is at present the case. 
So far as my experience has yet gone, I have not met with any symptoms 
which have led me to think that it has produced bad effects ; and I 
have known many patients sleep quietly through labor, without ex- 
pressing any excessive suffering, or asking for chloroform, who, under 
ordinary circumstances, would have been most urgently calling for 
relief. It occasionally happens that the patient cannot retain the 
chloral, from its tendency to produce sickness ; it may then be readily 
given per rectum in the form of enema. 

Generally speaking, we do not think of giving chloroform until the 
os is fully dilated, the head descending, and the pains becoming pro- 
pulsive. It has often, indeed, been administered earlier, for the 
purpose of aiding the dilatation of a rigid cervix, and there is no 
doubt that it often succeeds well when employed in this way ; but I 
have already stated my belief that chloral answers this purpose better. 

There is one cardinal rule to be remembered in giving chloroform 
during the propulsive stage, and that is, that it should be administered 
intermittently, and never continuously. When the pain comes on a 
few drops may be scattered over a Skinner's inhaler, which affords one 
of the best means of administering it in labor, or placed within the 
folds of a handkerchief twisted into the form of a cone. During the 
acme of the pain the patient inhales it freely, and at once experiences a 
sense of great relief; and, as soon as the pain dies away, the inhaler 
should be removed. In the interval between the pains the effect of 
the drug passes off, so that the higher degree of anaesthesia should 
never be produced. Indeed, when properly given, consciousness 
should not be entirely abolished, and the patient, between the pains, 



310 LABOR. 

should be able to speak, and to understand what is said to her. This 
intermittent administration constitutes the peculiar safety of chloro- 
form administered in labor, and it is a fortunate circumstance that 
there are very few cases on record of death during the inhalation of 
chloroform for obstetric purposes. This is obviously due to the effect 
of each inhalation passing off before a fresh dose is administered. 

The effect on the pains should be carefully watched. If they 
become very materially lessened in force and frequency, it may be 
necessary to stop the inhalation for a short time, commencing again 
when the pains get stronger ; this effect may be often completely and 
easily prevented by mixing the chloroform with about one-third of 
absolute alcohol, which, originally recommended, I believe, by Dr. 
Sansom, increases the stimulating effects of chloroform, and thus 
diminishes its tendency to produce undue relaxation. The amount 
administered must vary, of course, with the peculiarities of each indi- 
vidual case and the effect produced, but it need never be large. As 
the head distends the perineum, and the pains get very strong and 
forcing, it may be given more freely and to the extent of inducing 
even complete insensibility just before the child is born. 

Ether. — In cases in which chloroform has lessened the force of the 
pains, ether may be given instead with great advantage. It certainly 
often acts well when chloroform is inadmissible on account of its effects 
on the pains, and, so far as my experience goes, it has not the property 
of relaxing the uterus, but, on the contrary, has sometimes seemed to 
me distinctly to intensify the pains. Of late I have used a mixture of 
one part of absolute alcohol, two of chloroform, and three of ether. 
This is less disagreeable than ether, and has not the over-relaxing 
effects of chloroform, and, on the whole, I believe it to be the best 
anaesthetic for midwifery practice. 

Bearing in mind the tendency of chloroform to produce uterine 
relaxation, more than ordinary precautions should always be taken 
against post-partum hemorrhage in all cases in which it has been freely 
administered. 

In cases of operative midwifery, it is often given to the extent of 
producing complete anaesthesia. In all such cases it should be admin- 
istered, when possible, by another medical man and not by the operator, 
because the giving of chloroform to the surgical degree requires the 
undivided attention of the administrator, and no man can do this and 
operate at the same time. I once learnt an important lesson on this 
point. I had occasion to apply the forceps in the case of a lady who 
insisted on having chloroform. ^Yhen commencing the operation I 
noticed some suspicious appearances about the patient, who was a large 
stout woman, with a feeble circulation. I therefore stopped, allowed 
her to regain consciousness, and delivered her without anaesthesia, 
much to her own annoyance. Just one month after labor she went to 
a dentist to have a tooth extracted, and took chloroform, during the 
inhalation of which she died. This impressed on my mind the lesson 
that no man can do two things at the same time. The partial uncon- 
sciousness of incomplete anaesthesia, in which the patient is restless and 
tossing about, renders the application of forceps, as well as all other 



A \ l.STII KSIA IN LABOR. 311 

operations, very difficult. Therefore, unless the patienl can be com- 
pletely and fully anaesthetized, it is better to operate without chloroform 
being given at all. 

[In the United States the dangers attending the use of chloroform 
in obstetric practice have, in large measure, banished it from the lying- 
in chamber. Some obstetricians in our chief cities still resort toil with 
little hesitation, believing that by great carefulness in its adminis- 
tration, and by the substitution of ether in exceptional eases, all danger 
may be avoided. Others have a very great fear of it, and universally 
trust to the safer anaesthetic. It is an error to suppose that the par- 
turient state robs chloroform of much of its danger, the apparent 
immunity being due to its intermittent and incomplete administration ; 
complete anesthesia being but a fraction less dangerous than in surgical 
operations upon women who are not pregnant. Dr. Lusk, already 
quoted, after a large experience with the use of chloroform, says: 
"Patients in labor do not enjoy any absolute immunity from the pernicious 
effects of chloroform." 1 It is much to be regretted that this more 
pleasant anaesthetic is so much more dangerous than ether as an 
inhalant ; but in consideration of the difference of risk, that of their 
relative effects upon the nose and trachea is scarcely to be considered. 
Chloroform acts upon the respiratory centres just as ether does; and 
this is an element of danger in each, but is capable of being counter- 
acted by artificial respiration. But, beyond this, chloroform is far 
more dangerous, in acting upon the motor ganglia of the heart and 
producing sudden death. According to the experiments of Vulpian 
upon animals, not more than one case of cardiac failure in forty can be 
restored by artificial respiration. He affirms that there is danger at 
the commencement, during the course, and at the close of chloroformiza- 
tion, and even some hours or days subsequent to it. Nelaton made the 
important discovery that the cerebral anaemia produced by chloroform, 
with its accompanying death-like condition, might be remedied by r 
long perseverance in artificial respiration with the patient turned head 
downward. 

Anaesthesia in labor is much less popular, both with obstetricians and 
patients in this country, than it was soon after its introduction. Im- 
provements in the purity of sulphuric ether have made the narcosis 
more reliable, but the general effect upon patients varies very decidedly, 
being all that can be desired in some, and just the reverse in others. 
Some of the undesirable effects I have witnessed are intoxication, with 
cessation of labor, hysterical excitement, nightmare, and post-partum 
inertia and hemorrhage. I have also witnessed the most delightful 
results from ether that could be desired. In a small, delicate mult- 
ipara whose mother died of phthisis, and to whom I had been obliged 
to administer stimulants in the first and much of the second stage of 
labor, the use of ether had the effect of revolutionizing her condition. 
Her pulse became strong ; her expulsive power increased ; she had no 
suffering ; the placenta was expelled without accompanying blood ; 
and there was no subsequent uterine relaxation. But such cases are, 
unfortunately, exceptional. — Ed.] 

\} Opus cit.] 



312 LABOR. 



CHAPTEE Y. 

PELVIC PRESENTATIONS. 

Under the head of pelvic presentations it is customary to include all 
cases in which any part of the lower extremities of the child presents. 
By some these are further subdivided into breech, footling, and knee 
presentations ; but, although it is of consequence to be able to recognize 
the feet and the knee when they present, so far as the mechanism and 
management of delivery are concerned, the cases are identical, and r 
therefore, may be most conveniently considered together. 

Frequency. — Presentations coming under this head are far from 
uncommon ; those in which the breech alone occupies the pelvis are 
met with, according to Churchill, once in fifty-two labors, while Rams- 
botham estimates that it presents more frequently, viz., once in 38.8 
labors. Footling presentations occur only once in ninety-two cases. 
They are probably often the mere conversion of original breech pres- 
entations, the feet having come down during the labor, either in con- 
sequence of the sudden escape of the liquor amnii, when the breech was 
still freely movable above the brim, or from some other cause. Knee 
presentations are extremely rare, as may be readily understood if it be 
borne in mind that to admit them the thighs must be extended, hence 
the vertical measurement of the child must be greatly increased, and 
therefore it could not be readily accommodated within the uterine 
cavity, unless of unusually small size. As a matter of fact, Mme. La 
Chapelle found only one knee presentation in upward of 3000 cases. 

The causes of pelvic presentations are not known. They are 
probably the same as those which produce other varieties of mal- 
presentation, especially an excess of liquor amnii and slight pelvic 
contraction ; and it is not unlikely that, in certain women, there may 
be some peculiarity in the shape of the uterine cavity which favors 
their production. It would be difficult otherwise to explain such a 
case as that mentioned by Velpeau, in which the breech presented in 
six labors. 

Prognosis. — The results, as regards the mother, are in no way more 
unfavorable than in vertex presentation. The first stage of the labor 
is generally tedious, since the large rounded mass of the breech does 
not adapt itself so well as the head to the lower segment of the uterus, 
and dilatation of the cervix is consequently apt to be retarded. The 
second stage is, however, if anything, more rapid than in vertex cases ; 
and even when it is protracted, the soft breech does not produce such 
injurious pressure on the maternal structures as the hard and unyield- 
ing head. 

The result is very different as regards the child. Dubois calculated 



PELVIC PRESENTATIONS. 313 

that one out of eleven children was stillborn. Churchill estimates the 

mortality a> much higher, viz., one in three and one-fifth. The latter 
certainly indicates a larger Dumber of stillbirths than is consistent 
with the experience of most practitioners, and more than should occur 
it' the cases be properly managed ; but there can be do doubt that the 
risk to the child i>. eveo under the most favorable circumstances, very 
great. Eveu when the child is not lost, it may be seriously injured. 
Dr. Ruge* lias tabulated a series of twenty-nine cases in which there 
were found to be fractures of bones or other injuries. 1 

The chief source of danger is pressure on the umbilical cord, in the 
interval elapsing betweeu the birth of the body and the head. At this 
time the cord is very generally compressed between the head of the 
child and the pelvic walls, so that circulation in its vessels is arrested. 
Hence the aeration of the foetal blood cannot take place; and, pul- 
monary respiration not having been yet established, the child dies 
asphyxiated. There are other eonditions present which tend, although 
in a minor degree, to produce the same result. One of these is that 
the placenta is probably often separated by the uterine contractions 
when the bulk of the body is beiug expelled, as, indeed, takes place 
under analogous circumstances when the vertex presents; the necessary 
result being the arrest of placental respiration. Joulin thinks that 
the same effect may be produced by the compression of the placenta 
between the contracted uterus and the hard mass of the foetal skull. 
Probably all these causes combine to arrest the functions of the pla- 
centa ; and, if the delivery of the head, and consequently the establish- 
ment of pulmonary respiration, be delayed, the death of the child is 
almost inevitable. The corollary is that the danger to the child is in 
direct proportion to the length of time that elapses between the birth 
of the body and that of the head. 

The risk to the child is greater in footling than in breech cases, 
because in the former the maternal structures are less perfectly dilated, 
in consequence of the small size of the feet and thighs, and, therefore, 
the birth of the head is more apt to be delayed. 

Diagnosis. — Inasmuch as the long axis of the child corresponds 
with the long axis of the uterus in pelvic, as in vertex presentations, 
there is nothing in the shape of the uterus to arouse suspicion as to the 
character of the case. Still it is often sufficiently easy to recognize a 
pelvic presentation by abdominal examination, if we have occasion to 
make one. The facility with which it may be done depends a good 
deal on the individual patient. If she be not very stout, and if the 
abdominal parietes be lax and non-resistant, we shall generally be 
able to feel the round head at the upper part of the uterus, much firmer 
and more defined in outline than the breech. The conclusion will be 
fortified if we hear the foetal heart beating on a level with, or above, 
the umbilicus. The greater resistance on one side of the abdomen will 
also enable us to decide, with tolerable accuracy, to which side the 
back of the child is placed. Information thus acquired is, at the best, 
uncertain ; and we can never be quite sure of the existence of a pelvic 

i Bull. gen. de Therap., August, 1875. 



314 LABOR. 

presentation until we can corroborate the diagnosis by vaginal exam- 
ination. 

[In view of the greater risk to the life of the foetus in a delivery by 
the breech over that by the vertex, it is advisable, when the position 
is determined while the membranes are still intact, to change the 
presentation from pelvic to cephalic by external bimanual manipula- 
tion. — Ed.] 

The first circumstance to excite suspicion on examination per 
vaginam, even when the os is undilated, is the absence of the hard 
globular mass felt through the lower segment of the uterus, so charac- 
teristic of vertex presentations. When the os is sufficiently open to 
allow the membranes to protrude, although the presenting part is too 
high up to be within reach, we may be struck with the peculiar shape 
of the bag of membranes, which, instead of being rounded, projects a 
considerable distance through the os, like the finger of a glove. This 
is a peculiarity met with in all malpresentations alike, and is, indeed, 
much less distinct in breech than in footling presentations, because in 
the former the membranes are more stretched, just as they are in vertex 
cases. When the membranes rupture, instead of the waters dribbling 
away by degrees, they often escape with a rush, in consequence of the 
pelvic extremity not filling up the lower part of the uterus so accu- 
rately as the head, which acts as a sort of ball-valve, and prevents the 
sudden and complete discharge of the waters. 

Often on first examining, even when the membranes are ruptured, 
the presentation is too high up to be made out accurately. All that 
we can be certain of is, that it is not the head ; and the case must be 
carefully watched, and examinations frequently repeated, until the 
precise nature of the presentation can be established. If the breech 
present, the finger first impinges on a round, soft prominence, on 
depressing which a bony protuberance, the tuber ischii, can be felt. 
On passing the finger upward it reaches a groove beyond which a 
similar fleshy mass, the other buttock, can be felt. In this groove 
various characteristic points, diagnostic of the presentation, can be 
made out. Toward one end we can feel the movable tip of the coccyx, 
and above it the hard sacrum, with its rough projecting prominences. 
These points, if accurately made out, are quite characteristic, and re- 
semble nothing in any other presentation. In front there is the anus, 
in which it is sometimes, but by no means always, possible to insert 
the tip of the finger. If this can be done, it is easy to distinguis it 
from the mouth, with which it might be confounded, by observing 
that the hard alveolar ridges are not contained within it. Still more 
in front we may find the genital organs, the scrotum in male children 
being often much swollen if the labor has been protracted. Thus it is 
often possible to recognize the sex of the child before birth. 

The breech might be mistaken for the face, especially if the latter 
be much swollen ; but this mistake can readily be avoided by feeling 
the spinous processes of the sacrum. 

The knee is recognized by its having two tuberosities with a depres- 
sion between them. It might be confounded with the heel, the elbow, 
or the shoulder. From the heel it is distinguished by having two 



PELVIC PRESENTATIONS. 315 

tuberosities instead of one; from the elbow, by the latter having one 
sharp tuberosity, with a depression on one side, instead of a central 
depression and two lateral prominences; and from the shoulder, by 
the latter being more rounded, having only one prominence, running 
from which the acromion and clavicle can be traced. 

The foot may be mi-taken for the hand. This error will be avoided 
by remembering that all the toes are in the same line, and that the 
great toe cannot be brought into apposition with the others, as the 
thumb can with the fingers. The internal border of the foot is much 
thicker than the external, whereas the two borders of the hand are of 
the same thickness. Moreover, the foot is articulated at right angles 
to the leg, and cannot be brought into a line with it, as the hand can 
with the arm. Finally, the projection of the calcaneum is character- 
istic, and resembles nothing in the hand. 

Mechanism. — As is the case in other presentations, obstetricians 
have very variously subdivided breech presentations, with the effect of 
needlessly complicating the subject. The simplest division, and that 
which will most readily impress itself on the memory of the student, 
is to describe the breech as presenting in four positions, analogous to 
those of the vertex, the sacrum being taken as representing the occiput, 
and the positions being numbered according to the part of the pelvis 
to which it points. Thus we have — 

First, or left sacro-anterior (sacro-lseva anterior, s.L.A., correspond- 
ing to the first position of the vertex). The sacrum of the child points 
to the left foramen ovale of the mother. 

Second, or right sacro-anterior (sacro-dextra anterior, S.d.a., corre- 
sponding to the second vertex position). The sacrum of the child 
points to the right foramen ovale of the mother. 

Third, or right sacroposterior (sacro-dextra posterior, s.d.p., corre- 
sponding to the third vertex position). The sacrum of the child points 
to the right sacro-iliac synchondrosis of the mother. 

Fourth, or left sacro-posterior (sacro-lseva posterior, s.l.p., corre- 
sponding to the fourth vertex position). The sacrum of the child 
points to the left sacro-iliac synchondrosis of the mother. 

Of these, as with the corresponding vertex positions, the first (s.l.a.) 
and third (s.d.p.) are the most common, their comparative frequency, 
no doubt, depending on the same causes. The mechanical conditions 
to which the presenting part is subjected are also identical, but the 
alterations of position of the breech in its progress are by no means so 
uniform as those of the head, on account of its less perfect adaptation 
to the pelvic cavity. The mechanism of the delivery of the shoulders 
and head in breech presentations, moreover, is of much greater prac- 
tical importance than that of the body in vertex presentations, inas- 
much as the safety of the child depends on its speedy and satisfactory 
accomplishment. Bearing these facts in mind, it will suffice to describe 
briefly the phenomena of delivery in the first (s.l.a.) and third (s.d.p.) 
breech positions. 

Position of the Child at Brim. — In the first position (s.l.a.) (Fig. 
113) the sacrum of the child points to the left foramen ovale; its back 
is consequently placed to the left side of the uterus and anteriorly, and 



316 



LABOR 



its abdomen looks to the right side of the uterus and posteriorly. The 
sulcus between the buttocks lies in the right oblique diameter of the 
pelvis, while the transverse diameter of the buttocks lies in the left 
oblique diameter, the left buttock being most easily within reach. As 
in vertex presentations, the hips of the child lie on the same level at the 
pelvic brim, although Xaegele describes the left hip as placed lower 
than the right. 



Fig. 113. 




First, or left sacroanterior position (s.l.a.) of the breech. 



As the pains act on the body of the child, the breech is gradually 
forced through the pelvic cavity, retaining the same relations as at the 
brim, its progress being generally more slow than that of the head, 
until it reaches the lower pelvic strait, when the same mechanism which 
produces rotation of the occiput comes to operate upon it. The result 
is a rotation of the child's pelvis, so that its transverse diameter comes 
to lie approximately in the antero-posterior diameter of the outlet, its 
antero-posterior diameter corresponds to the transverse diameter of the 
mother's pelvis, the left hip lies behind the pubes, and the right toward 
the sacrum. This rotation, which is admitted by the majority of obste- 
tricians, is altogether denied by JSaegele. There can be no doubt, 
however, that it does generally take place, but by no means so con- 
stantly as the corresponding rotation of the vertex ; and it is not 
uncommon for it to be entirely absent, and for the hips to be born in 
the oblique diameter of the outlet. The body of the child is said fre- 
quently not to follow the movement imparted to the hips, so that there 
is more or less of a twist in the vertebral column. 

The left hip uoav becomes firmly fixed behind the pubes, and a 
movement of extension, analogous to that of the head in vertex pres- 
entations, takes place. The right, or posterior, hip revolves around 
the fixed one, gradually distends the perineum, and is expelled first, 



PELVIC PRESENTATIONS. 



317 



the left hip rapidly following. As soon as l>oth hips are born, the feet 
slip out, unless the legs are completely extended upon the child's abdo- 
men. The shoulders soon follow, lying iu the left oblique diameter 
of the pelvis ( Fig. 1 1 I). 1 The left shoulder rotates forward behind 
the pubes, where it becomes fixed, the right shoulder sweeping over 
the perineum, and being born first. The arm- of the child are gener- 
ally found placed upon its thorax, and are born before the shoulder-. 
Sometimes they are extended over the child's head, thus causing con- 
siderable delay, and greatly increasing the risk to the child. It is 
now generally admitted that such extension is most apt to occur when 
traction has been made on the child's body with the view of hastening 
delivery, and that it is rarely met with when the expulsion of the body 
is left entirely to the normal powers. 



Fig. 114. 




Passage of the shoulders and partial rotation of the thorax. 

Delivery of the Head. — TThen the shoulders are expelled the head 
enters the pelvis in the opposite, or right oblique diameter, the face 
looking to the right saero-iliac synchondrosis. As the greater part of 
the child is now expelled, and as the head has entered the vagina, the 
uterus, having a comparatively small mass to contract upon, must 
obviously act at a mechanical disadvantage. Still the pressure of the 
head on the vagina is a powerful inciter, the accessory muscles of 
parturition are brought into strong action, and there may be sufficient 
force to insure expulsion of the head without artificial aid. On account 
of the great resistance to the descent of the occiput from its articula- 
tion with the spinal column, the pains have the effect of forcing down 
the anterior portion of the head, and this insures the complete flexion 
of the chin upon the sternum (Fig. 115). This is a great advantage 
from a mechanical point of view, as it causes the short occipitofrontal 
diameter of the head to enter the pelvis in the axis of the uterus and 
the brim. If the head should be in a state of partial extension — as 
sometimes happens when the pelvis is unusually roomy — the occipito- 
mental diameter is placed in a similar relation to the brim, a position 
certainly less favorable to the easy birth of the head. As the head 

1 This figure, however, represents the position of the shoulders in the second (s.d.a.) position ) 



318 



LABOR 



descends it experiences a movement of rotation, the occiput passing 
forward and to the right, behind the pnbic arch, the face turning 
backward into the hollow of the sacrum. The body of the child will 
be observed to follow this movement, so that its back is turned toward 
the mother's abdomen, its anterior surface to the perineum. The nape 
of the neck now becomes firmly fixed under the arch of the pubes, the 
pains act chieflv on the anterior portion of the head, and cause it to 
sweep over the perineum, the chin being first born, then the mouth 
and forehead, and lastly the occiput. 




Descent of the head. 



It is needless to describe the differences between the mechanism of 
the second (s.d.a.) and first (s.l.a.) positions, which the student who 
has mastered the subject of vertex presentations will readily under- 
stand. It is necessary, however, to say a few words as to sacro- 
posterior positions, choosing for that purpose the third (s.d.p.), which 
is the more common of the two. This is exactly the opposite of the 
first (s.l.a.) position. The sacrum of the child points to the right 
sacro-iliac synchondrosis, its abdomen looks forward and to the left 
side of the mother. The transverse diameter of the child's pelvis lies 
in the left oblique diameter, the right hip being anterior. The birth 
of the body generally takes place exactly in the way that has been 
already described, the right hip being toward the pubes. 

As the head descends into the pelvis the occiput most usually rotates 
along its right side — the rotation having been often already partially 
eifected when that of the hips had been made — until it comes to rest 
behind the pubes, the face passing backward along the left side of the 
pelvis into the hollow of the sacrum. This change corresponds exactly 
to the anterior rotation of the occiput in occipito-posterior positions, 
and is the natural and favorable termination. 

Sometimes, further rotation does not take place, and the occiput 
then turns backward into the hollow of the sacrum. "What then 
generally occurs is, that the pains continue, for the reason already 
mentioned, to depress the chin and produce strong flexion of the face 
on the sternum, the occiput becoming fixed on the anterior border of 



PELVIC PRESENTATIONS. 31$ 

tln> perineum. The pains continuing fco ad chiefly on the anterior 
part of the head, the face is borne first behind the pubes, the occiput 
only slipping over the perineum alter the forehead lias been ex- 
pelled. 

The second mode of termination of sucli positions is mentioned in 
most works, on the authority of one or two recorded cases; but 
although mechanically possible, it is certainly an event of extreme 
rarity. The chin, instead of being flexed on the sternum, is greatly 
extended, so that the face of the child looks upward toward the pelvic 
brim. The chin then hitches over the upper edge; of the pubes and 
becomes fixed there, while the force of the uterine contractions is ex- 
pended on the posterior part of the head, which descends through the 
pelvis, distending the perineum, and is born first, the face subsequently 
following. 

The mechanism of the delivery of the body and head in cases in 
which the feet originally present does not differ, in any important 
respect, from that which has been already described, and requires no 
separate notice. 

Treatment. — From what has been said of the natural mechanism,, 
it is evident that one of the most fruitful causes of difficulty and com- 
plication is undue interference on the part of the practitioner. It is, 
no doubt, tempting to use traction on the partially born trunk in the 
hope of expediting delivery ; but Avhen it is remembered that this is 
almost certain to produce extension of the arms above the head, and 
subsequently extension of the occiput on the spine, both of which 
seriously increase the difficulty of delivery, the necessity of leaving 
the ease as much as possible to Nature will be apparent. 

Having once, therefore, determined the existence of a pelvic pres- 
entation, nothing more should be done until the birth of the breech. 
The membranes should be even more carefully prevented from prema- 
turely rupturing than in vertex presentations, since they serve to dilate 
the genital passages better than does the presenting part. Hence they 
should be preserved intact, if possible, until they reach the floor of the 
pelvis, instead of being punctured as soon as the os is fully dilated. 
The breech when born should be received and supported in the palm 
of the hand. 

When the body is expelled as far as the umbilicus, the dangers to 
the child commence ; for now the cord is apt to be pressed between 
the body of the child and the pelvic walls. To obviate this risk as 
much as possible, a loop of the cord should be pulled down, and car- 
ried to that part of the pelvis where there is most room, which will 
generally be opposite one or the other sacro-iliac synchondrosis. As 
long as the cord is freely pulsating we may be satisfied that the life of 
the child is not gravely imperilled, although delay is fraught with 
danger from other sources which have been already indicated. In 
most cases the arms now slip out ; but it may happen, even without 
any fault on the part of the accoucheur, that they are extended above 
the head, and it is of great importance that we should be thoroughly 
acquainted with the best means of liberating them from their abnormal 
po-ition. 



320 LABOR. 

They must, of course, never be drawn directly downward, or the 
almost certain result would be fracture of the fragile bones. We 
should endeavor to make the arm sweep over the face and chest of 
the child, so that the natural movements of its joints should not be 
opposed. If the shoulders be within easy reach, the finger of the 
accoucheur should be slipped over that which is posterior — because 
there is likely to be more space for this manoeuvre toward the sacrum 
— and gently carried downward toward the elbow, which is drawn 
over the face, and then onward, so as to liberate the forearm. The 
same manoeuvre should then be applied to the opposite arm. It may 
be that the shoulders are not easily reached, and then they may be 
depressed by altering the position of the child's body. If this be 
carried well up to the mother's abdomen, the posterior shoulder will 
be brought lower down ; and, by reversing this procedure and carry- 
ing the body back over the perineum, the anterior shoulder may be 
similarly depressed. It is only very exceptionally, however, that these 
expedients are required,, 

Birth of the Head. — The arms being extracted, some degree of 
artificial assistance is, at this time, almost always required. If there 
be much delay, the child will almost certainly perish. Attempts have 
been made, in cases in which delivery of the head could not be rapidly 
effected, to establish pulmonary respiration by passing one or two 
fingers into the vagina, so as to press it back and admit air to the 
child's mouth, or by passing a catheter or tube into the mouth. Neither 
of these expedients is reliable, and we should rather seek to aid Nature 
in completing the birth of the head as rapidly as possible. The first 
thing to do, supposing the face to have rotated into the cavity of the 
sacrum, is to carry the body of the child well up toward the pubes 
and abdomen of the mother without applying any traction for fear of 
interfering with the all-important flexion of the chin on the sternum. 

If now the patient bear down strongly, the natural powers may be 
sufficient to complete delivery. If there be any delay, traction must 
be resorted to, and we must endeavor to apply it in such a way as to 
insure flexion. For this purpose, while the body of the child is 
grasped by the left hand, and drawn upward toward the mother's 
abdomen, the index and middle fingers of the right hand are placed 
on the back of the child's neck, so that their tips press on either side 
of the base of the occiput, and push the head into a state of flexion. 
In most w r orks we are advised to pass the index and middle fingers of 
the left hand at the same time over the child's face, so as to depress 
the superior maxilla. Dr. Barnes insists that this is quite unnecessary, 
and that extraction in the manner indicated, by pressure on the occiput, 
is quite sufficient. Should it not prove so, flexion of the chin may be 
very effectually assisted by downward pressure on the forehead through 
the rectum. One or two fingers of the left hand can readily be inserted 
into the bowel, and the expulsion of the head is thus materially 
facilitated. 

By far the most powerful aid, however, in hastening delivery of the 
head, should delay occur, is pressure from above. This has been, 
strangely enough, almost altogether omitted by writers on the subject. 



PELVH' PRESENTATIONS. 321 

It has beeD strongly recommended by Professor Penrose, and there 
can be no question of its utility. Indeed, as the Uterus contracts 
tightly around the head, uterine expression can be applied almost 
directly to the head itself, and withoul any fear of deranging its 
proper relation to the maternal passages. It is very seldom indeed 
that a judicious combination of traction on the part of the accoucheur, 
with firm pressure through the abdomen applied by an assistant, will 
fail in effecting delivery of the head before the delay has had time to 
prove injurious to the child. 

Application of the Forceps to the After-coming- Head. — Many 
accoucheurs — among others, Meigs and Rigby — advocate the applica- 
tion of the forceps when there is delay in the birth of the after-coming 
head. If the delay be due to want of expulsive force in a pelvis of 
normal size, manual extraction, in the manner just described, will be 
found to be sufficient in almost every case, and preferable, as being 
more rapid, easier of execution, and safer to the child. The forceps 
may be quite properly tried, if other means have failed; especially if 
there be some disproportion between the size of the head and the 
pelvis. 

Difficulties in delivery may also occur in sacro-posterior positions. 
Up to the time of the birth of the head the labor usually progresses as 
readily as in the sacro-anterior positions. If the forward rotation of 
the hips do not take place, much subsequent difficulty may be pre- 
vented by gently favoring it by traction applied to the breech during 
the pains, the linger being passed for this purpose into the fold of the 
groin. 

It is after the birth of the shoulders that the absence of rotation is 
most likely to prove troublesome. It has been recommended that the 
body should then be grasped, in the interval between the pains, and 
twisted around so as to bring the occiput forward. It is by no means 
certain, however, that the head would follow the movement imparted 
to the body, and there must be a serious danger of giving a fatal twist 
of the neck by such a manoeuvre. The better plan is to direct the 
face backward, toward the cavity of the sacrum, by pressing on the 
anterior temple during the continuance of a pain. In this way the 
proper rotation will generally be effected without much difficulty, and 
the case will terminate in the usual way. 

If rotation of the occiput forward do not occur, it is necessary for 
the practitioner to bear in mind the natural mechanism of delivery 
under such circumstances. In the majority of cases the proper plan is 
to favor flexion of the chin by upward pressure on the occiput, and to 
exert traction directly backward, remembering that the nape of the 
neck should be fixed against the anterior margin of the perineum. If 
this be not remembered, and traction be made in the axis of the pelvic 
outlet, the delivery of the head will be seriously impeded. In the rare 
cases in which the head becomes extended, and the chin hitches on the 
upper margin of the pubes, traction directly forward and upward may 
be required to deliver the head ; but before resorting to it care should be 
taken to ascertain that backward extension of the head has really 
taken place. 

21 



322 LABOR. 

It remains for us to consider the measures which may be adopted in 
those troublesome cases in which the breech refuses to descend, and 
becomes impacted in the pelvic cavity, either from uterine inertia, or 
from disproportion between the breech and the pelvis. The peculiar 
shape of the presenting part unfortunately renders such cases very 
difficult to manage. 

Three measures have been chiefly employed : 1st, the forceps ; 
2d, bringing down one or both feet, so as to break up the presenting 
part, and convert it into a footling case ; 3d, traction on the breech, 
either by the fingers, a blunt hook, or fillet passed over the groin. 

Forceps. — The forceps has generally been considered unsuited for 
breech cases in consequence of its construction to fit the foetal head, 
which renders it liable to slip when applied to the breech. The objec- 
tion, probably to a great extent true with reference to most forceps, 
seems not to hold good when the axis-traction forceps of Tarnier or 
Simpson is used. Lusk strongly recommends it, and Harvey, of 
Calcutta, has published six consecutive cases in which he employed, 
this method of delivery, in three with complete success. Truzzi, 1 who 
has written strongly in favor of the forceps in difficult breech cases, 
prefers it greatly to traction either by the fingers or the fillet when the 
breech is high in the pelvis, and recommends that, in order to secure 
a strong hold, the blades should be passed so that their extremities 
extend above the crests of the foetal ilia. I have only used it myself 
in one or two cases, but in these the results were extremely good, and 
delivery was effected with a facility which surprised me, and I can see 
no objection to a cautious trial of the instrument. [A better-fitting 
instrument is the special breech-forceps, with oval fenestra?, flat-edged 
blades, and long superimposed shanks, modelled to fit the sides of the 
breech over the trochanters and ilia. — Ed.] 

Bringing" Down a Foot. — Barnes insists on the superiority of the 
second plan, and there can be no question that, if a foot can be got 
down, the accoucheur has a complete control over the progress of the 
labor which he can gain in no other way. If the breech be arrestd at 
or near the brim, there will generally be no great difficulty in effecting 
the desired object. It will be necessary to give chloroform to the 
extent of complete anaesthesia, and to pass the hand over the child's 
abdomen in the same manner, and with the same precautions, as in 
performing podalic version, until a foot is reached, which is seized 
and pulled down. If the feet be placed in the usual way close to the 
buttocks, no great difficulty is likely to be experienced. If, however, 
the legs be extended on the abdomen, it will be necessary to introduce 
the hand and arm very deeply, even u x to the fundus of the uterus, a 
procedure which is always difficult, and which may be very hazardous. 
Xor do I think that the attempt to bring down the feet can be safe 
when the breech is low down and fixed in the pelvic cavity. A cer- 
tain amount of repression of the breech is possible, but it is evident that 
this cannot be safely attempted when the breech is at all low down. 

Traction on the Groin. — Under such circumstances traction is our 

1 Gaz. Med. Ital. Lomb., August, 1883. 



PRESENTATIONS OF THE FACE. 323 

only resource, and this is always difficult and often unsatisfactory. Of 
all contrivances for this purpose none is better than the hand of the 
accoucheur. The index finger can generally be -lipped over the groin 
without difficulty, and traction can be applied during the pain-. Fail- 
ing this, or w hen it proves insufficient, an attempt should be made to 
pass a fillet over the groins. A sofl silk handkerchief, or a skein of 
worsted, answers best, but it i< by no means easy to apply. The sim- 
plest plan, and one which is tar better than the expensive instruments 
contrived for the purpose, is to take a stout piece of copper wire and 
bend it double into the form of a hook. The extremity of this can 
generally be guided over the hips, and through its looped end the 
fillet is passed. The wire is now withdrawn, and carries the fillet 
over the groins. I have found this simple contrivance, which can be 
manufactured in a few moments, very useful, and by means of such a 
fillet very considerable tractive force ean be employed. The use of a 
soft fillet is in every way preferable to the blunt hook which is con- 
tained in most obstetric bags. A hard instrument of this kind is 
quite as difficult to apply, and any strong traction employed by it is 
almost certain to seriously injure the delicate foetal structures over 
which it is placed. As an auxiliary the employment of uterine 
expression should not be forgotten, since it may give material aid 
when the difficulty is only due to uterine inertia. 

Embryotomy. — Failing all endeavors to deliver by these expedients, 
there is no resource left but to break up the presenting part by scissors, 
or by craniotomy instruments ; but fortunately so extreme a measure 
is but rarely necessary. 

Examination of the Child. — After a difficult breech labor is com- 
pleted the child should be carefully examined to see that the bones of 
the thighs and arms have not been injured. Fractures of the thigh 
are far from uncommon in such cases, and the soft bones of the newly 
born child will readily and rapidly unite if placed at once in proper 
splints. 



CHAPTEE VI. 

PRESENTATIONS OF THE FACE. 

Presentations of the face are bv no means rare ; and, although in 
the great majority of eases they terminate satisfactorily by the un- 
assisted powers of Nature, yet every now and again they give rise to 
much difficulty, and then they may be justly said to be amongst the 
most formidable of obstetric complications. It is, therefore, essential 
that the practitioner should thoroughly understand the natural history 
of this variety of presentation, with the view of enabling him to 
intervene with the best prospect of success. 



324 LABOR. 

The older accoucheurs had very erroneous views as to the mechanism 
and treatment of these cases, most of them believing that delivery was 
impossible by the natural efforts, and that it was necessary to inter- 
vene by version in order to effect delivery. Smellie recognized the 
fact that spontaneous delivery is possible, and that the chin turns for- 
ward and under the pubes ; but it was not until long after his time, 
and chiefly after the appearance of Mme. La Chapelle's essay on the 
subject, that the fact that most cases could be naturally delivered was 
fully admitted and acted upon. 

Frequency. — The frequency of face presentations varies curiously 
in different countries. Thus, Collius found that in the Rotunda 
Hospital there was only 1 case in 497 labors, although Churchill gives 
1 in 249 as the average frequency in British practice ; while in 
Germany this presentation is met with once in 169 labors. The only 
reasonable explanation of this remarkable difference is, that the dorsal 
decubitus, generally followed on the Continent, favors the transforma- 
tion of vertex presentations into those of the face. 

The mode in which this change is effected — for it can hardly be 
doubted that, in the large majority of cases, face presentation is clue 
to a backward displacement of the occiput after labor has actually 
commenced, but before the head has engaged in the brim — has been 
made the subject of various explanations. 

It has generally been supposed that the change is induced by a 
hitching of the occiput on the brim of the pelvis, so as to produce 
extension of the head, and descent of the face ; the occurrence being 
favored by the oblique position of the uterus so frequently met with 
in pregnancy. Hecker 1 attaches considerable importance to a pecu- 
liarity in the shape of the fcetal head generally observed in face pres- 
entations, the cranium having the dolicho-cephalous form, prominent 
posteriorly, with the occciput projecting, which has the effect of in- 
creasing the length of the posterior cranial lever arm, and facilitating 
extension when circumstances favoring it are in action. Dr. Duncan 2 
thinks that uterine obliquity has much influence in the production of 
face presentation, but in a different way to that above referred to. He 
points out that, when obliquity is very marked, a curve in the genital 
passages is produced, the convexity of which is directed to the side 
toward Avhich the uterus is deflected. When uterine contraction com- 
mences, the fcetus is propelled downward, and the part corresponding 
to the concavity of the curve is acted on to the greatest advantage by 
the propelling force, and tends to descend. Should the occiput happen 
to lie in the convexity of the curve so formed, the tendency will be 
for the forehead to descend. In the majority of cases its descent will 
be prevented by the increased resistance it meets with, in consequence 
of the greater length of the anterior cranial lever arm ; but, if the 
uterine obliquity be extreme, this may be counterbalanced, and a face 
presentation ensues. The influence of this obliquity is corroborated 
by the observation of Baudelocque, that the occiput in face presenta- 
tions almost invariably corresponds to the side of the uterine obliquity. 

1 Ueber die Schadelforni bei Gesichtslagen. 

2 Edin. Med. Journ., vol. xv. 



PRESENTATIONS OF THE FACE. 325 

A further corroboration is afforded by the fad thai in face presentation 

tin 1 occiput is much more frequently directed to the right than to the 
left ; while right lateral obliquity of the uterus is also much more 
common. 

These theories assume that face presentations are produced during 
labor. In a lew cases they certainly exist before labor has commenced. 
It is possible, however, as we know that uterine contractions exist in- 
dependently of actual labor, that similar causes may also be in opera- 
tion, although less distinctly, before the commencement of labor. 

The diagnosis is often a matter of considerable difficulty at an 
early period of labor, before the os is fully dilated and the membranes 
ruptured, and when the face lias not entered the pelvic cavity. The 
finger then impinges on the rounded mass of the forehead, which may 
very readily be mistaken for the vertex. At this stage the diagnosis 
may be facilitated by abdominal palpation in the way suggested by 
Hecker. If the face is presenting at the brim, palpation will enable 
us to distinguish a hard, firm, and rounded body, immediately above 
the pubes, which is the forehead and sinciput ; on the other side will 
be felt an indistinct, soft substance, corresponding to the thorax and 
neck. "When labor is advanced, and the head has somewhat descended, 
or when the membranes are ruptured, we should be able to make out 
the nature of the presentation with certainty. The diagnostic marks 
to be relied on are the edges of the orbits, the prominence of the nose, 
the nostrils (their orifices showing to which part of the pelvis the chin 
is turned), and the cavity of the mouth, with the alveolar ridges. If 
these be made out satisfactorily, no mistake should occur. The most 
difficult cases are those in which the face has been a considerable time 
in the pelvis. Under such circumstances the cheeks become greatly 
swollen and pressed together, so as to resemble the nates. The nose 
might then be mistaken for the genital organs, and the mouth for the 
anus. The orbits, however, and the alveolar ridges, resemble nothing 
in the breech, and should be sufficient to prevent error. 

Considerable care should be taken not to examine too frequently 
and roughly, otherwise serious injury to the delicate structures of the 
face might be inflicted. When once the presentation has been satis- 
factorily diagnosed, examinations should be made as seldom as possible, 
and only to assure ourselves that the case is progressing satisfactorily. 

Mechanism. — If we regard face presentations, as we are fully justified 
in doing, as being generally produced by the extension of the occiput 
in what were originally vertex presentations, Ave can readily under- 
stand that the position of the face in relation to the pelvis must cor- 
respond to that of the vertex. This is, in fact, what is found to be 
the case, the forehead occupying the position in which the occiput 
would have been placed had extension not occurred. 

The face, then, like the head, may be placed with its long diameter 
corresponding to almost any of the diameters of the brim, but most 
generally it lies either in the transverse diameter, or between this and 
the oblique, while, as it descends in the pelvis, it more generally occu- 
pies one or other of the oblique diameters. It is common in obstetric 
works to describe two principal varieties of face presentation, viz., the 



326 LABOR. 

right and left mento-iliac, according as the chin is turned to one or 
other side of the pelvis. It is better, however, to classify the positions 
in accordance with the part of the pelvis to which the chin points. 
We may, therefore, describe four positions of the face, each being 
analogous to one of the ordinary vertex presentations, of which it is 
the transformation. 

The Four Positions generally met with. — First position (mento- 
dextra posterior, m.d.p.). The chin points to the right sacro-iliac 
synchondrosis, the forehead to the left foramen ovale, and the long 
diameter of the face lies in the right oblique diameter of the pelvis. 
This corresponds to the first position of the vertex, and, as in that, the 
back of the child lies to the left side of the mother. 

Second position (mento-lseva posterior, m.l.p.). The chin points to 
the left sacro-iliac synchondrosis, the forehead to the right foramen 
ovale, and the long diameter of the face lies in the left oblique 
diameter of the pelvis. This is the conversion of the second vertex 
position. 

Third position (mento-lseva anterior, m.l.a.). The forehead (Fig. 
116) points to the right sacro-iliac synchondrosis, the chin to the left 

Fig. 116. 




Third position (m.l.a.') in face presentations. 

foramen ovale, and the long diameter of the face lies in the right 
oblique diameter of the pelvis. This is the conversion of the third 
vertex position. 

Fourth position (mento-dextra anterior, m.d.a.). The forehead points 
to the left sacro-iliac synchondrosis, the chin to the right foramen 
ovale, and the long diameter of the face lies in the left oblique 
diameter of the pelvis. This is the conversion of the fourth vertex 
position. 



PRESENTATIONS OF THE FACE. 3'2( 

The relative frequency of these presentations is not yet positively 
ascertained. It is certain that there is not the preponderance of first 
facial (m.d.p.) that there is of first vertex (o.l.a.) positions, and this 
may, no doubt, be explained by the supposition that an unusual vertex 
position may of itself facilitate the transformation into a face pres- 
entation. Winckel concludes that, cceteris paribus, a face presentation 
is more readily produced when the back of the child lies to the right 
than when it lies to the left side of the mother ; the reason for this 
being probably the frequency of right lateral obliquity of the litems. 
We shall presently see that, with very rare exceptions, it is absolutely 
essential that the chin should rotate forward under the pubes before 
delivery can be accomplished ; and, therefore, we may regard the third 
and fourth face positions, in which the chiu from the first points ante- 
riorly, as more favorable than the first and second. 

The mechanism of delivery in face is practically the same as in 
vertex presentations ; and we shall have no difficulty in understand- 
ing it if we bear in mind that in face cases the forehead takes the 
place of, and represents the occiput in, vertex presentations. For the 
purpose of description we will take the first position of the face. 

1. Extension. — The first step consists in the extension of the head, 
which is effected by the uterine contractions as soon as the membranes 
are ruptured. By this the occiput is still more completely pressed 
back on the nape of the neck, and the fronto-mental, rather than the 
mento-bregmatic, diameter is placed in relation to the pelvic brim. 
This corresponds to the stage of flexion in vertex presentations. 

The chin descends below the forehead, from precisely the same 
cause as the occiput in vertex presentations. On account of the ex- 
tended position of the head the presenting face is divided into portions of 
unequal length in relation to the vertebral column, through which the 
force is applied, the longer lever arm being toward the forehead. The 
resistance is, therefore, greatest toward the forehead, which remains 
behind while the chin descends. 

2. Descent. — As the pains continue, the head (the chin being still 
in advance) is propelled through the pelvis. It is generally said that 
the face cannot descend, like the occiput, down to the floor of the 
pelvis, its descent being limited by the length of the neck. There is 
here, however, an obvious misapprehension. The neck, from the chin 
to the sternum, Avhen the head is forcibly extended, measures from 
three and a half to four inches, a length that is more than sufficient to 
admit of the face descending to the lower pelvic strait. As a matter 
of fact, the chin is frequently observed in mento-posterior positions to 
descend so far that it is apparently endeavoring to pass the perineum 
before rotation occurs. At the brim the two sides of the face are on a 
level, but as labor advances the right cheek descends somewhat, the 
caput succedaneum forms on the malar bone, and, if a secondary caput 
suceedaneum form, on the cheek. 

3. Rotation is by far the most important point in the mechanism 
of face presentations ; for unless it occurs, delivery, with a full-sized 
head and an average pelvis, is practically impossible. There are, no 
doubt, exceptions to this rule, which must be separately considered, 



328 



LABOR, 



but it is certain that the absence of rotation is always a grave and for- 
midable complication of face presentation. Fortunately it is only 
very rarely that this is not effected. The mechanical causes are pre- 
cisely those which produce rotation of the occiput forward in vertex 



Fig. 117. 




Rotation forward of chin. 



presentations. As it is accomplished, the chin passes under the arch 
of the pubes, and the occiput rotates into the hollow of the sacrum 
(Fig. 117) ; and then commences — 

4. Flexion, a movement which corresponds to extension in vertex 
cases. The chin passes as far as it can under the pubic arch, and there 
becomes fixed. The uterine force is now expended on the occiput, 
which revolves, as it were, on its transverse axis (Fig. 118), the under 
surface of the chin resting on the pubes as a fixed point. This move- 
ment goes on until, at last, the face and occiput sweep over the 
distended perineum. 

5. External rotation is precisely similar to that which takes place 
in head presentations, and, like it, depends on the movements imparted 
to the shoulders. 

Such is the natural course of delivery in the vast majority of cases; 
but, in order fully to understand the subject, it is necessary to study 
those rare cases in which the chin points backward, and forward rota- 
tion does not occur. These may be taken to correspond to the 
occipito-posterior positions, in which the face is born looking to the 
pubes ; but, unlike them, it is only very exceptionally that delivery 
can be naturally completed. The reason of this is obvious, for the 
occiput gets jammed behind the pubes, and there is no space for the 
fronto-mental diameter to pass the antero-posterior diameter of the out- 
let (Fig. 119). Cases are indeed recorded in which delivery has been 



P R K S E N l A 1 I N S OF Til E F A C E . 



329 



effected with the chin looking posteriorly ; but there i-; every reason 

to believe that this can only happen when the head Is either unusually 
small, or the pelvis unusually large. In such cases the forehead i- 



Fir.. 11^. 




Passage of the head through the external parts in face presentation. 

pressed down until a portion appears at the ostinm vagina?, when it 
becomes firmly fixed behind the pubes, and the chin, after many 



Fig. 119. 




Illustrating the position of the head when forward rotation of the chin does not take place. 

efforts, -lips over the perineum. When this is effected, flexion occurs, 
and the occiput is expelled without difficulty. The forehead is 
probably always on a lower level than the chin. 



330 LABOR. 

Dr. Hicks 1 has published a paper in which he attempts to show 
that this termination of lace presentations is not so rare as is generally 
supposed, and he gives a single instance in which he effected delivery 
with the forceps ; but he practically admits that special conditions are 
necessary, such as the " antero-posterior diameter of the outlet particu- 
larly ample," and a diminished size of the head. When delivery is 
effected it is probable, as Cazeaux has pointed out, that the face lies in 
the oblique diameter of the outlet, and that the chin depresses the soft 
structures at the side of the sacro-ischiatic notch, which yield to the 
extent of a quarter of an inch or more, and thereby permit the passage 
of the occipito-mental diameter of the head. It must, however, be 
borne w T ell in mind, that spontaneous delivery in mento-posterior 
positions is the rare exception, and that, supposing rotation does not 
occur — and it often does so at the last moment — artificial aid in one 
form or another will be almost certainly required. 

Prognosis of Pace Presentations. — As regards the mother, in the 
great majority of cases the prognosis is favorable, but the labor is apt 
to be prolonged, and she is, therefore, more exposed to the risks 
attending tedious delivery. As regards the child, the prognosis is 
much more unfavorable than in vertex presentations. Even when the 
anterior rotation of the chin takes place in the natural way, it is 
estimated that one out of ten children is stillborn ; while, if not, the 
death of the child is almost certain. This increased infantile mortality 
is evidently due to the serious amount of pressure to which the child 
is subjected, and probably depends in many cases on cerebral conges- 
tion, produced by pressure on the jugular veins, as the neck lies in the 
pelvic cavity. Even when the child is born alive, the face is always 
greatly swollen and disfigured. In some cases the deformity produced 
in this way is excessive, and the features are often scarcely recog- 
nizable. This disfiguration passes away in a few days ; but the prac- 
titioner should be aware of the probability of its occurrence, and 
should warn the friends, or they might be unnecessarily alarmed, and 
possibly might lay the blame on him. 

Treatment. — After what has been said as to the mechanism of 
delivery in face presentation, it is obvious that the proper course is to 
leave the case alone, in the expectation of the natural efforts being 
sufficient for complete delivery. Fortunately, in the large majority of 
cases, this course is attended by a successful result. 

The old accoucheurs, as has been stated, thought active interference 
absolutely essential, and recommended either podalic version, or the 
attempt to convert the case into a vertex presentation, by inserting the 
hand and bringing down the occiput. The latter plan was recom- 
mended by Baudelocque, and is even yet followed by some accoucheurs. 
Thus Dr. Hodge 2 advises it in all cases in which face presentation is 
detected at the brim ; but although it might not have been attended 
with evil consequences in his experienced hands, it is certainly alto- 
gether unnecessary, and would infallibly lead to most serious results if 
generally adopted. It may, however, be allowable in certain cases in 

1 Obstet. Trans., 1866, vol. vii. p. 57. 2 System of Obstetrics, p. 335. 



PRESENTATIONS E THE FACE. 331 

which the face remain- above the brim, and refuses t<> descend into the 
pelvic cavity. Even then it is questionable whether podalic version 
should not be preferred, as being easier of performance, giving, when 
once effected, a much more complete control over delivery, and being 
Less painful to the mother. Version is certainly preferable to the 
application of the forceps, which are Introduced with difficulty in so 
high a position of the face, and do not take a secure hold, provided 
the face has not emerged from the mouth of the uterus. If it has 
pa— ed through the cervix, version could not be effected without serious 
risk of rupture of the uterus. 

Schatz 1 has more recently suggested the rectification of face presenta- 
tions at an early stage, before the rupture of the membranes, by manip- 
ulation through the abdomen. He raises the foetal body by pressure 
on the shoulder and breast through the abdominal wall by one hand, 
while the breech is raised and steadied by the other. By this means 
the occiput is elevated, and then the breech is pressed downward, when 
head flexion is produced by the resistance of the pelvic walls. Of this 
method I have had no practical experience, but it obviously requires 
an unusual amount of skill and practice in abdominal palpation. 

\Yhen once the face has descended into the pelvis, difficulties may 
arise from two chief causes : uterine inertia, and non-rotation forward 
of the chin. 

The treatment of the former class must be based on precisely the 
same general principles as in dealing with protracted labor in vertex 
presentations. The forceps may be applied with advantage, bearing 
in mind the necessity of getting the chin under the pubes, and, when 
this has been effected, of directing the traction forward, so as to make 
the occiput slowly and gradually distend and sweep over the perineum. 

The secoud class of difficult face cases is much more important, 
and may try the resources of the accoucheur to the utmost. Our first 
endeavor must be, if possible, to secure the anterior rotation of the 
chin. For this purpose various manoeuvres are recommended. By 
some, we are advised to introduce the finger cautiously into the mouth 
of the child, and draw the chin forward during a pain ; by others, to 
pass the finger up behind the occiput and press it backward during the 
pain. Schroeder points out that the difficulty often depends on the 
fact of the head not being sufficiently extended, so that the chin is not 
on a lower level than the forehead ; and that rotation is best promoted 
by pressing the forehead upward with the finger during a pain, so as 
to cause the chin to descend. Penrose 2 believes that non-rotation is 
generally caused by the want of a point oVappui below, on account of 
the face being unable to descend to the floor of the pelvis, and that, if 
this is supplied, rotation will take place. In such cases he applies the 
hand, or the blade of the forceps, so as to press on the posterior cheek. 
By this means the necessary point cVappui is given ; and he relates 
several interesting cases in which this simple manoeuvre was effectual 
in rapidly terminating a previously lengthy labor. Any, or all, of 
these plans may be tried. We must bear in mind, in using them, that 

> Arch. f. Gyn.. 1873, Bd. v. S. 313. 

2 Amer. Supplement to Obst. Journ., 1S76-77, vol. iv. p. 1 . 



332 



LABOR. 



rotation is often delayed until the face is quite at the lower pelvic 
strait, so that we need not too soon despair of its occurring. If, how- 
ever, in spite of these manoeuvres, it does not take place, what is to be 
done? If the head has not passed through the mouth of the uterus, 
turning would be the simplest and most effectual plan. I have suc- 
ceeded in delivering in this way, when all attempts at producing rota- 
tion had failed ; but generally the face will be too decidedly engaged 
to render it possible. An attempt might be made to bring down the 
occiput by the vectis, or by a fillet ; but if the face be in the pelvic 
cavity, it is hardly possible for this plan to succeed. An endeavor 
may be made to produce rotation by the forceps ; but it should be 
remembered that rotation of the face mechanically in this way is very 
difficult, and much more likely to be attended with fatal consequences 
to the child than when it is effected by the natural efforts. In using 
forceps for this purpose, the second or pelvic curve is likely to prove 
injurious, and a short straight instrument is to be preferred. If rota- 
tion be found to be impossible, an endeavor may be made to draw the 
face downward, so as to get the chin over the perineum, and deliver 
in the mento-posterior position ; but unless the child be small, or the 
pelvis very capacious, the attempt is unlikely to succeed. Finally, if 
all these means fail, there is no resource left but lessening the size of 
the head by craniotomy, a dernier ressort which, fortunately, is very 
rarely required, but which is certainly preferable to long-continued 
and violent endeavors to deliver with the chin pointing backward. 

Brow Presentations. — It sometimes happens that the head is par- 
tially extended, so as to bring the os frontis into the brim of the pelvis, 
and form what is described as a brow presentation. Should the head 
descend in this manner, the difficulties, although not insuperable, are 
apt to be very great, from the fact that the long cervico-frontal diam- 
eter of the head is engaged in the pelvic cavity. The diagnosis is not 

difficult, for the os frontis will be detected 
by its rounded surface, while the anterior 
fontanelle is within reach in one direc- 
tion, the orbit and root of the nose in 
another. 

Fortunately, in the large majority of 
cases, brow presentations are spontane- 
ously converted into either vertex or face 
presentations, according as flexion or ex- 
tension of the head occurs ; and these 
must be regarded as the desirable termi- 
nations and the ones to be favored. For 
this, purpose upward pressure must be 
made on one or other extremity of the 
presenting part during a pain, so as to 



Fig. ]20. 




Brow presentation, subsequently 
converted into that of the face. 
(After Lusk.) 



favor flexion or extension 



or, if the 



parts be sufficiently dilated, an attempt 
may be made to pass the hand over the occiput and draw it down, thus 
performing cephalic version. The latter is the plan recommended by 
Hodge, who describes the operation as easy. Long, in an excellent 



DIFFICULT OCCIPITO— POSTERIOB POSITIONS. 

paper on this subject, has given figures to .-how thai correction of the 
malpresentation by manipulation has given better results than any 
other method of treatment.' It is questionable, however, if a well- 
marked brow presentation be distinctly made out while the head is 
still at the brim, whether podalic version would nol be the easiesl and 
best operation. If the forehead has descended too low lor this, and 
if the endeavor to convert it into either a face or vertex presentation 
tails, the forceps will probably he required. In such cases the face 
generally turns toward the pubes, the superior maxilla becomes fixed 
behind the pubic arch, and the occiput sweeps over the perineum. 
Wry great difficulty is likely to be experienced, and, if conversion 
into either a vertex or face presentation cannot be effected, craniotomy 
is not unlikely to be required. After birth the head will be unusually 
disfigured from the pressure to which it has been subjected, the swell- 
ing mainly forming over the forehead, between the root of the nose 
and the anterior angle of the greater fontanelle (Fig. 120). 



CHAPTEE VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

A few words may be said in this place as to the management of 
oecipito-posterior positions of the head, especially of those in which 
forward rotation of the occiput does not take place. It has already 
been pointed out that, in the large majority of these cases, the occiput 
rotates forward without any particular difficulty, and the labor termi- 
nates in the usual way with the occiput emerging under the arch of 
the pubes. 

In a certain number of cases such rotation does not occur, and diffi- 
culty and delay are apt to follow. The proportion of cases in which 
face-to-pubes terminations of oecipito-posterior positions occur has 
been variously estimated, and they are certainly more common than 
most of our text-books lead us to expect. Dr. Uvedale AVest, 1 who 
studied the subject with great care, found that labor ended in this 
way in 7!J out of 2585 births, all these deliveries being exceptionally 
difficult. 

Causes of Face-to-Pubes Delivery. — He believed that forward 
rotation of the head is prevented by the absence of flexion of the chin 
on the sternum, so that the long occipitofrontal (o.F.), instead of the 
short sub-occipito-bregmatic (s.o.B.), diameter of the head is brought 
into contact with the pelvic diameter; hence the occiput is no longer 
the lowest point, and is not subjected to the action of those causes 

i American Journal of Obstetrics, 1SS5, vol. xviii. p. 897. 
2 Cranial Presentations, p. 33. 



334 LABOR. 

which produce forward rotation. Dr. Macdonald, who has written a 
thoughtful paper on the subject, 1 believes that the non-rotation forward 
of the occiput is chiefly due to the large size of the head, in conse- 
quence of which "the forehead gets so wedged into the pelvis anteriorly 
that its tendency to slacken and rotate backward does not come into 
play." Dr. West's explanation, which has an important bearing on 
the management of these cases, seems to explain most correctly the 
non-occurrence of the natural rotation. 

The important question for us to decide is, How can we best assist 
in the management of cases of this kind when difficulties arise, and 
labor is seriously retarded ? 

Mode of Treatment of Such Cases. — Dr. West, insisting strongly 
on the necessity of complete flexion of the chin on the sternum, advises 
that this should be favored by upward pressure on the frontal bone, 
with the view of causing the chin to approach the sternum, and the 
occiput to descend, and thus to come within the action of the agencies 
which favor rotation. Supposing the pains to be strong, and the 
fontanelle to be readily within reach, we may, in this way, very pos- 
sibly favor the descent of the occiput, and without injuring the 
mother, or increasing the difficulties of the case in the event of the 
manoeuvre failing. The beneficial effects of this simple expedient are 
sometimes very remarkable. In two cases in which I recently adopted 
it, labor, previously delayed for a length of time without any apparent 
progress, although the pains were strong and effective, was in each 
instance rapidly finished almost immediately after the upward press- 
ure was applied. The rotation of the face backward may at the same 
time be favored by pressure on the pubic side of the forehead during 
the pains. 

Others have advised that the descent of the occiput should be pro- 
moted by downward traction, applied by the vectis or fillet. The 
latter is the plan specially advocated by Hodge ; 2 and the fillet cer- 
tainly finds one of its most useful applications in cases of this kind, 
as being simpler of application and probably more effective than the 
vectis. 

Although any of these methods may be adopted, a word of caution 
is necessary against prolonged and over-active endeavors at producing 
flexion and rotation when that seems delayed. All who have watched 
such cases must have observed that rotation often occurs spontaneously 
at a very advanced period of labor, long after the head has been 
pressed down for a considerable time to the very outlet of the pelvis, 
and when it seems to have been making fruitless endeavors to emerge ; 
so that a little patience will often be sufficient to overcome the diffi- 
culty. 

Bataillard 3 advises the introduction of the antisepticized hand when 
rotation does not occur, with which the head is dislodged from the 
sacrum, and gently rotated forward. He relates many instances in 
which this manoeuvre was successful. Should it fail, and farther 

i Edin. Med. Journ., 1874-75, vol. xx. p. 302. 

2 System of Obstetrics, p. 308. 

3 Ann. de Gyn., August, 1889. 



DIFFICULT OCCIJ'ITO-POSTERIOR POSITIONS. 335 

assistance be required, there is no reason why the forceps should not 
be used. The instrument is not more difficult to apply than under 
ordinary circumstances, nor, as a rule, i> much more traction necessary. 

Dr. Maedonald, indeed, in the paper already alluded to, maintains that 
in persistent occipito-posterior positions there i- almost always a want 

of proportion between the head and the pelvis, and that, therefore, the 
forceps will be generally required, and he prefers them to any artificial 

attempts at rectification. Some peculiarities in the mode of delivery 
are necessary to bear in mind. In most Avorks it is taught that the 
operator should pay special attention to the rotation of the head, and 
should endeavor to impart this movement by turning the occiput for- 
ward during extraction. Tims Tyler Smith says : " In delivery with 
the forceps in occipito-posterior presentations, the head should be 
slowly rotated during the process of extraction so as to bring the 
vertex toward the pubic arch, and thus convert them into occipito- 
anterior presentations." The danger accompanying any forcible 
attempt at artificial rotation will, however, be evident on slight con- 
sideration. It is true that in many cases, when simple traction is 
applied, the occiput will, of itself, rotate forward, carrying the instru- 
ment with it. But that is a very different thing from forcibly twisting 
the head around with the blades of the forceps, without any assurance 
that the body of the child will follow the movement. It is impossible 
to conceive that such violent interference would not be attended with 
serious risk of injury to the neck of the child. If rotation do not 
occur, the fair inference is that the head is so placed as to render 
delivery with the face to the pubes the best termination, and no 
endeavor should be made to prevent it. This rule of leaving the 
rotation entirely to Xature, and using traction only, has received the 
approval of Barnes and most modern authorities, and is the one which 
recommends itself as the most scientific and reasonable. 

There are cases in which the pelvic curve of the forceps is of 
doubtful utility. When applied in the usual way the convexitv of 
the blades points backward. If rotation accompany extraction, the 
blades necessarily follow the movement of the head, and their convex 
edges will turn forward. It certainly seems probable that snch a 
movement would snbject the maternal soft parts to considerable risk. 
I have, however, more than once seen such rotation of the instrument 
happen without any apparent bad result ; but the dangers are obvious. 
Hence it would be a wise precaution, either to use a pair of straight 
forceps for this particnlar operation, or to remove the blades and leave 
the case to be terminated by the natural powers, when the head is at 
the lower strait, and rotation seems about to occur. Prof. Richardson 1 
advises that when forceps are applied in persistent occipito-posterior 
positions, they should be introduced with the pelvic curve reversed. 
He claim- for this method that the traction is chiefly exerted on the 
occiput, where it is most needed, which thereby descends and produces 
the necessary flexion of the chin on the sternum. The forceps are 
then removed, and, if the pains are sufficient, rotation forward is sure 

1 Medical Communications of the Massachusetts Medical Society, 1S-S5, vol. xiii. No. 4. 



336 LABOK. 

to take place. Of this plan I have no personal experience. When 
there is no rotation, more than usual care should be taken with the 
perineum, which is necessarily much stretched by the rounded occiput. 
Indeed, the risk to the perineum is very considerable, and, even with 
the greatest care, it may be impossible to avoid laceration. 

Bearing these precautions in mind, delivery with the forceps in 
occipito-posterior positions offers no special difficulties or dangers. 

[Version by the Vertex. — The following are the teachings of 
several eminent American obstetricians upon the management of 
occipito-posterior positions : 

1. " In primitive oblique occipito-posterior positions of the head 
Nature will almost without exception cause spontaneous rotation of 
the occiput to the symphysis pubis ; but to favor this movement the 
bag of waters should be preserved." 

2. " Spontaneous rotation, as a rule, does not begin until the head 
meets with resistance from the floor of the pelvis : hence no effort to 
force rotation should be made until Nature has proved herself inade- 
quate." 

3. " Where rotation forward is prevented, it is probably due to the 
position of the occiput having been originally directly backward, and 
only becoming oblique after the descent of the head into the pelvis, 
the position of the child's body preventing the anterior movement of 
its occiput ; that is, the sixth position of Hodge has changed into a 
fourth or fifth, but will not without assistance become a first or 
second." 

4. " If, then, rotation is not spontaneous after the head reaches the 
floor of the pelvis, version by the vertex will not take place, except it 
be forced by the vectis or forceps." 

Use of the Hand in Occipito-posterior Positions. — The intro- 
duction of the hand for the purpose of effecting version by the vertex 
was strongly advocated by the late Dr. John S. Parry, of Philadelphia, 
whose hand was very small and thin, and could be used to great ad- 
vantage. Prof. Ottavio Morisani, of Naples, is said to use his with 
even greater success, because of its smaller size. Large hands should 
not be used in primiparse. By this manoeuvre I once brought an 
occiput under the pubic arch of a primipara in three pains, after she 
had labored for hours to deliver herself. — Ed.] 



CHAPTER Till. 

PRESENTATIONS OF THE SHOULDER, ARM, OR TRUNK.— 
COMPLEX PRESENTATIONS.— PROLAPSE OF THE FUNIS. 

In the presentations already considered the long diameter of the 
foetus corresponded with that of the uterine cavity, and in all of them 
the birth of the child by the maternal efforts was the general and 



PRESENTATIONS OF SHOULDER, ETC. 337 

normal termination of labor. We have now to discuss those important 
cases in which the long diameter of the foetus and uterus do not cor- 
respond, but in which the long foetal diameter lies obliquely across the 
uterine cavity. In the Large majority of these it is either the shoulder 

Or some part of tin 4 upper extremity that presents ; for it is an admitted 
fact that, although other parts of the body, such as the back or ab- 
domen, may, in exceptional case's, lie over the os at an early period of 
labor, yet, as labor progresses, such presentations are almost always 
converted into those of the upper extremity. 

For all practical purposes we may confine ourselves to a considera- 
tion of shoulder presentations ; the further subdivision of these into 
elbow or hand presentations being no more necessary than the division 
of pelvic presentations into breech, knee, and footling eases, since the 
mechanism and management are identical, whatever part of the upper 
extremity presents. 

There is this great distinction between the presentations we are now 
considering and those already treated of, that, on account of the rela- 
tions of the foetus to the pelvis, delivery by the natural powers is 
impossible, except under special and very unusual circumstances that 
can never be relied upon. Intervention on the part of the accoucheur 
is, therefore, absolutely essential, and the safety of both the mother 
and child depends upon the early detection of the abnormal position 
of the foetus; for the necessary treatment, which is comparatively easy T 
and safe before labor has been long in progress, becomes most difficult 
.and hazardous if there have been much delay. 

Fig. 121. 



Dorso-anterior presentation of the arm (s.l.a.). 

Position of the Foetus. — Presentations of the upper extremity or 
trunk are often spoken of as transverse presentations or cross-births ; 
but both of these terms are misleading, as they imply that the foetus 
is placed transversely in the uterine cavity, or that it lies directly 
across the pelvic brim. As a matter of fact, this is never the case, for 

22 



338 



LABOR. 



the child lies obliquely in the uterus, not indeed in its long axis, but 
in one intermediate between its long and transverse diameters. 

Two great divisions of shoulder presentations are recognized : the 
one in which the back of the child looks to the abdomen of the mother 
(Fig. 121), and the other in which the back of the child is turned 
toward the spine of the mother (Fig. 122). Each of these is sub- 

FlG. 122. 




Dorso-posterior presentation of the arm (s.d.p.), 



divided into two subsidiary classes, according as the head of the child 
is placed in the right or left iliac fossa. Thus in dorso-anterior posi- 
tions, if the head lie in the left iliac fossa (left scapula anterior — scapula- 
lseva anterior, s.l.a.), the right shoulder of the child presents ; if in 
the right iliac fossa (right scapula anterior — scapula-dextra anterior, 
S.D.A.), the left. So in dorso-posterior positions, if the head lie in the 
left iliac fossa (left scapula posterior — scapula-laeva posterior, S.L.P.), the 
left shoulder presents ; if in the right, the right (right scapula posterior — 
scapula-dextra posterior, s.d.p.). 1 Of the two classes the dorso-anterior 
positions are more common — in the proportion, it is said, of two to one. 
The causes of shoulder presentation are not well known. Amongst 
those most commonly mentioned are prematurity of the foetus, aud 
excess of liquor amnii ; either of these, by increasing the mobility of 
the foetus in utero, would probably have considerable influence. The 
fact that it occurs much more frequently amongst premature births has 
long been recognized. Undue obliquity of the uterus has probably some 
influence, since the early pains might cause the presenting part to 
hitch against the pelvic brim, and the shoulders to descend. An un- 
usually low attachment of the placenta to the inferior segment of the 

1 Left and right refer in this nomenclature, as in all positions, to the left and right side of the- 
mother without regard to that of the child. 



PRESENTATIONS OF SHOULDER, ETC. 339 

uterine cavity has been mentioned as a predisposing cause. In conse- 
quence of this the head docs not lie so readily in the lower uterine 
segment, and is apt to slip up into one of the iliac fossa?. This is sup- 
posed to explain the frequency of arm presentation in eases of partial 
or complete placenta prsevia. Danyau and Wigand believe that 
shoulder presentations are favored by irregularity in the shape of the 
uterine cavity, especially a relative increase in its transverse diameter. 
This theory has been generally discredited by writers, and it is cer- 
tainly not susceptible of proof; btit it seems far from unlikely that 
some peculiarity of shape may exist, not capable of recognition, but 
sufficient to influence the position of the foetus. How otherwise are 
we to explain those remarkable cases, many of which are recorded, in 
which similar malpositions occurred in many successive labors? Thus 
Joulin refers to a patient who had an arm presentation in three suc- 
cessive pregnancies, and to another who had shoulder presentation in 
three out of four labors, while Enstache, of Lille, 1 describes the case 
of a patient who had thirteen shoulder presentations out of fourteen 
deliveries. Certainly, such constant recurrences of the same abnor- 
mality could only be explained on the hypothesis of some very per- 
sistent cause such as that referred to. Pinard 2 states that shoulder 
presentations are seven times more common in multipara? than in pri- 
niiparse, in consequence, as he believes, of the laxity of the abdominal 
walls in the former, which allows the uterus to fall forward, and thus 
prevents the head entering the pelvic brim in the latter weeks of preg- 
nancy. It is probable that merely accidental causes have most influ- 
ence in the production of shoulder presentation, such as falls, or undue 
pressure exerted on the abdomen by badly fitting or tight stays. Par- 
tially transverse positions during pregnancy are certainly much more 
common than is generally believed, and may often be detected by 
abdominal palpation. The tendency is for such malpositions to be 
righted either before labor sets in, or in the early period of labor ; but 
it is quite easy to understand how any persistent pressure, applied in 
the manner indicated, may perpetuate a position which otherwise 
would have been only temporary. 

Prognosis and Frequency. — According to Churchill's statistics, 
shoulder presentations occur about once in 260 cases ; that is, onlv 
slightly less frequently than those of the face. Spiegelberg found it 
1 in 180 ; while in France the combined statistics of several accoucheurs 
show a frequency of 1 in 117. The prognosis to both the mother and 
child is much more unfavorable ; for he estimates that out of 235 cases, 
1 in 9 of the mothers and half the children were lost. The prognosis 
in each individual case will, of course, vary much with the period of 
delivery at which the malposition is recognized. If detected earlv, 
interference is easy, and the prognosis ought to be good ; whereas there 
are few obstetric difficulties more trying than a case of shoulder pre- 
sentation, in which the necessary treatment has been delayed until the 
presenting part has been tightly jammed into the cavity of the pelvis. 

Diagnosis. — Bearing this fact in mind, the paramount necessity of 

i Nouv. Arch. d'Obstet. et Gvn.. 1889. 

2 Annal. d'Hyg. pub. et de Mud., Jan. 1S79. 



340 LABOR. 

an accurate diagnosis will be apparent; and it is specially important 
that we should be able not only to detect that a shoulder or arm is pre- 
senting, but that we should, if possible, determine which it is, and how 
the body and head of the child are placed. The existence of a shoulder 
presentation is not generally suspected until the first vaginal examina- 
tion is made during labor. The practitioner will then be struck with 
the absence of the rounded mass of the foetal head, and, if the os be 
opened and the membranes protruding, by their elongated form, which 
is common to this and to other malpresentations. If the presenting 
part be too high to reach, as is often the case at an early period of 
labor, an endeavor should at once be made to ascertain the foetal posi- 
tion by abdominal examination. This is the more important as it is 
much more easy to recognize presentations of the shoulder in this way 
than those of the breech or foot ; and, at so early a period, it is often 
not only possible but comparatively easy, to alter the position of the 
foetus by abdominal manipulation alone and thus avoid the necessity 
of the more serious form of version. The method of detecting a 
shoulder presentation by examination of the abdomen has already been 
described (p. 129), and need not be repeated. The chief points to look 
for are, the altered shape of the uterus, and two solid masses, the head 
and the breech, one in either iliac fossa. The facility with which these 
parts may be recognized varies much in different patients. In thin 
women, with lax abdominal parietes, they can be easily felt, while in 
very stout women it may be impossible. Failing this method, we must 
rely on vaginal examinations ; although, before the membranes are 
ruptured, and when the presenting part is high in the pelvis, it is not 
always easy to gain accurate information in this way. The difficulty 
is increased by the paramount importance of retaining the membranes 
intact as long as possible. It should be remembered, therefore, that 
when a presentation of the superior extremity is suspected, the neces- 
sary examinations should only be made in the intervals between the 
pains when the membranes are lax, and never when they are rendered 
tense by the uterine contractions. 

As either the shoulder, the elboAv, or the hand may present, it will 
be best to describe the peculiarities of each separately, and the means 
of distinguishing to which side of the body the presenting part 
belongs. 

1. The shoulder is recognized as a round smooth prominence, at 
one point of which may often be felt the sharp edge of the acromion. 
If the finger can be passed sufficiently high, it may be possible to feel 
the clavicle, and the spine of the scapula. A still more complete ex- 
amination may enable us to detect the ribs and the intercostal spaces, 
which would be quite conclusive as to the nature of the presentation, 
and there is nothing resembling them in any other part of the body. 
At the side of the shoulder, the hollow of the axilla may generally be 
made out. 

In order to ascertain the position of the child, we have to find out 
in which iliac fossa the head lies. This may be done in two ways : 
1st, the head may be felt through the abdominal parietes by palpation ; 
and 2d, since the axilla always points toward the feet, if it point to 






PRESENTATIONS OP SHOULDER, ETC. 341 

the lift side the head must lie in the right iliac fossa ; if to the right, 
the head must be placed in the left iliac fossa. Again, the spine of the 
scapula must correspond to the back of the child, the clavicle to its 
abdomen ; and, by feeling one or the other, we know whether we have 
to {\o with a dorso-anterior or dorso-posterior position. It we cannot 
satisfactorily determine the position by these means, it is quite legiti- 
mate practice to bring down the arm carefully, provided the membranes 
are ruptured, so as to examine the hand, which will be easily recognized 
as right or left. This expedient will decide the point; but it is one 
which it is better to avoid, if possible, for it not only slightly increases 
the difficulty of turnings although perhaps not very materially, but the 
arm might possibly be injured in the endeavor to bring it down. 

The only part of the body likely to be taken lor the shoulder is the 
breech ; but in that its larger size, the groove in which the genital 
organs lie, the second prominence formed by the other buttock, and the 
sacral spinous processes, are sufficient to prevent a mistake. 

2. The elbow is rarely felt at the os, and may be readily recognized 
by the sharp prominence of the olecranon, situated behveen two lesser 
prominences, the condyles. As the elbow always points toward the 
feet, the position of the foetus can be easily ascertained. 

3. The hand is easy to recognize, and can only be confounded with 
the foot. It can be distinguished by its borders being of the same 
thickness, by the fingers being wider apart and more readily separated 
from each other than the toes, and above all by the mobility of the 
thumb, which can be carried across the palm, and placed in apposition 
with each of the fingers. 

It is not difficult to tell which hand is presenting. If the hand be in 
the vagina, or beyond the vulva, and within easy reach, we recognize 
which it is by laying hold of it as if Ave Avere about to shake hands. If 
the palm lie in the palm of the practitioner's hand, Avith the tAvo thumbs 
in apposition, it is the right hand ; if the back of the hand, it is the 
left. Another simple way is for the practioner to imagine his own 
hand placed in precisely the same position as that of the foetus ; and 
this will readily enable him to A'erifv the pre\ T ious diagnosis. A 
simple rule tells us how the body of the child is placed, for, prcwided 
Ave are sure the hand is in a state of supination, the back of the hand 
points to the back of the child, the palm to its abdomen, the thumb to 
the head, and the little finger to the feet. 

Mechanism. — It is perhaps hardly proper to talk of a mechanism 
of shoulder presentations, since, if left unassisted, they almost in- 
variably lead to the gravest consequences. Still, Xature is not entirely 
at fault eA^en here, and it is avcII to study the means she adopts to 
terminate these malpositions. 

Terminations of Shoulder Presentation. — There are two possible 
terminations of shoulder presentation. In one, known as spontaneous 
version, some other part of the foetus is substituted for that originally 
presenting ; in the other, spontaneous evolution, the foetus is expelled 
by being squeezed through the pelvis, without the originally presenting 
part being withdrawn. It cannot be too strongly impressed on the 
mind that neither of these can be relied on in practice. 



342 LABOR. 

Spontaneous version may occasionally occur before, or immediately 
after, the rupture of the membranes, when the foetus is still readily 
movable within the cavity of the uterus. A few authenticated cases 
are recorded in which the same fortunate issue took place after the 
shoulder had been engaged in the pelvic brim for a considerable time, 
or even after prolapse of the arm ; but its probability is necessarily 
much lessened under such circumstances. Either the head or the 
breech may be brought down to the os in place of the original pres- 
entation. 

The precise mechanism of spontaneous version, or the favoring 
circumstances, are not sufficiently understood to justify any positive 
statement with regard to it. 

Cazeaux believed that it is produced by partial or irregular contrac- 
tion of the uterus, one side contracting energetically, while the other 
remains inert, or only contracts to a slight degree. To illustrate how 
this may effect spontaneous version, let us suppose that the child is 
lying with the head in the left iliac fossa. Then if the left side of the 
uterus should contract more forcibly than the right, it would clearly 
tend to push the head and shoulder to the right side, until the head 
came to present instead of the shoulder. A very interesting case is 
related by Geneuil, 1 in which he was present during spontaneous 
version, in the course of which the breech was substituted for the left 
shoulder more than four hours after the rupture of the membranes. 
In this case the uterus was so tightly contracted that version was im- 
possible. He observed the side of the uterus opposite the head con- 
tracting energetically, the other remaining flaccid, and eventually the 
case ended without assistance, the breech presenting. The natural 
moulding action of the uterus, and the greater tendency of the long 
axis of the child to lie in that of the uterus, no doubt assist the trans- 
formation, and much must depend on the mobility of the foetus in any 
individual case. 

That such changes often take place in the latter weeks of pregnancy, 
and before labor has actually commenced, is quite certain, and they are 
probably much more frequent than is generally supposed. When spon- 
taneous version does occur, it is, of course, a most favorable event ; 
and the termination and prognosis of the labor are then the same as if 
the head or breech had originally presented. 

Spontaneous Evolution. — The mechanism of spontaneous evolu- 
tion, since it was first clearly worked out by Douglas, has been so 
often and carefully described that we know precisely how it occurs. 
Although every now and then a case is recorded in which a living 
child has been born by this means, such an event is of extreme rarity; 
and there is no doubt of the accuracy of the general opinion, that spon- 
taneous evolution can only happen when the pelvis is unusually roomy 
and the child small ; and that it almost necessarily involves the death 
of the foetus, on account of the immense pressure to which it is sub- 
jected. 

Two varieties are described, in one of which the head is first born, 

1 Annal. de Gynec., 1876, torn. v. p. 468. 



PRESENTATIONS OF SHOULDER, ETC, 



343 



in the other the breech ; in both the originally presenting arm remained 
prolapsed. The former is of extreme rarity, and is believed only to 

have happened with very premature children, whose bodies were; small 
and flexible, and when traction had been made on the presenting arm. 
Under such circumstances it can hardly be called a natural process, 
and we may eonline our attention to the latter and more common 
variety. 

Fig 123. 




Spontaneous evolution. (After Chiara.) This drawing was made from a patient who died 
undelivered, the body being frozen and bisected. 

What takes place is as follows : The presenting arm and shoulder 
are tightly jammed down, as far as is possible, by the uterine contrac- 
tions, and the head becomes strongly flexed on the shoulder. As much 
of the body of the foetus as the pelvis will contain becomes engaged, 
and then a movement of rotation occurs, which brings the body of the 
child nearly into the antero-posterior diameter of the pelvis (Fig. 123). 
The shoulder projects under the arch of the pubis, the head lying above 
the symphysis, and the breech near the sacro-iliac synchondrosis. It 
is essential that the head should lie forward above the pnbes, so that 
the length of the neck may permit the shoulder to project under the 
pubic arch, without any part of the head entering the pelvic cavity. 
The shoulder and neck of the child now become fixed points, around 



344 LABOR. 

which the body of the child rotates, and the whole force of the uterine 
contractions is expended on the breech. The latter, with the body, 
therefore, becomes more and more depressed, until, at last, the side of 
the thorax reaches the vulva, and, followed by the breech and inferior 
extremities, is slowly pushed out. As soon as the limbs are born the 
head is easily expelled. 

The enormous pressure to which the body is subjected in this process 
can readily be understood. As regards the practical bearings of this 
termination of shoulder presentations, all that need be said is, that, if 
we should happen to meet with a case in which the shoulder and 
thorax were so strongly depressed that turning was impossible, and in 
which it seemed that Nature was endeavoring to effect evolution, we 
should be justified in aiding the descent of the breech by traction on 
the groin, before resorting to the difficult and hazardous operation of 
embryotomy and decapitation. 

Treatment. — It is unnecessary to describe specially the treatment 
of shoulder presentation, since it consists essentially in performing the 
operation of turning, which is fully described elsewhere. It is only 
needful here to insist on the advisability of performing the operation 
in the way which involves the least interference with the uterus. 
Hence, if the nature of the case be detected before the membranes are 
ruptured, an endeavor should be made — and ought generally to suc- 
ceed — to turn by external manipulation only. If we can succeed in 
bringing; the breech or head over the os in this way, the case will be 
little more troublesome than an ordinary presentation of these parts. 
Failing in this, turning by combined external and internal manipula- 
tion should be attempted ; and the introduction of the entire hand 
should be reserved for those more troublesome cases in which the 
waters have long drained away, and in which both these methods are 
inapplicable. 

Should all these means fail, we must resort to the mutilation of the 
child by embryulcia or decapitation, probably the most difficult and 
dangerous of all obstetric operations. In fourteen cases in the United 
States the Cesarean section has been performed under these circum- 
stances, with a successful result to the mother in ten. In seven cases 
the arm protruded, in three the pelvis was small, and in two it was 
deformed. Three of the women were subsequently delivered naturally. 1 
[The four deaths were produced as follows : Case 3 was in labor ninety- 
six hours, three days under a midwife, and died of exhaustion in seven- 
teen hours. Case 7 was twenty-six hours in labor, and had been under 
the care of a midwife, who had given ergot freely ; she was much pros- 
trated, and died in twelve hours. Case 9 would in all probability 
have recovered had she not risen from her bed on the third day to 
defend her mother against her husband, who came home drunk. The 
fright, excitement, and exertion caused her death in a few hours. Case 
13 was three days in labor, and ergot was largely used; forceps, ver- 
sion, and craniotomy were all tried. Death came on the tenth day 
from the bursting of an abscess of the abdominal wall into the peri- 

1 Harris, note to 6th American edition. 






etc. 345 

toneal cavity, resulting in Beptic peritonitis. Case 11 was operated 
upon in June, 1880; was up and al work in a month; became preg- 
nant in two and a half more, and bore a child naturally in twelve and 

a halt' month- after the operation. The uterine wound was dosed with 
two silver-wire sutures. 

This operation certainly promises well in cases of impaction with 
an arm protruding where there has been no deforming pelvic disease. 
With the new conservative method such cases should he saved in large 
proportion in the United States. Will embryulcia or decapitation be 
likely to succeed as well in this country? — Ed.] 

Complex Presentations. — There are various so-called complex pres- 
entations in which more than one part of the foetal body presents. Thus 
we may have a hand or a foot presenting with the head, or a foot and 
hand presenting simultaneously. The former do not necessarily give 
rise to any serious difficulty, for there is generally suffieient room for 
the head to pass. Indeed, it is unlikely that either the hand or foot 
should enter the pelvic brim with the head, unless the head was unusu- 
ally small, or the pelvis more than ordinarily capacious. As regards 
treatment, it is, no doubt, advisable to make an attempt to replace the 
hand or foot by pushing it gently above the head in the intervals 
between the pains, and to maintain it there until the head be fully 
engaged in the pelvic cavity. The engagement of the head can be 
hastened by abdominal pressure, which will prove of great value. 
Failing this, all we can do is to place the presenting member at the 
part of the pelvis where it will least impede the labor, and be the least 
subjected to pressure ; and that will generally be opposite the temple 
of the child. As it must obstruct the passage of the head to a certain 
extent, the application of the forceps may be necessary. When the 
feet and hands present at the same time, in addition to the confusing 
nature of the presentation from so many parts being felt together, there 
is the risk of the hands coming down, and converting the case into one 
of arm presentation. It is the obvious duty of the accoucheur to pre- 
vent this by insuring the descent of the feet, and traction should be 
made on them, either with the fingers or with a fillet, until their descent, 
and the ascent of the hands, are assured. 

Dorsal Displacement of the Arm. — In connection with this sub- 
ject may be mentioned the curious dorsal displacement of the arm first 
described by Sir James Simpson, 1 in which the forearm of the child 
becomes thrown across and behind the neck. The result is the forma- 
tion of a ridge or bar, which prevents the descent of the head into the 
pelvis by hitching against the brim (Fig. 124). The difficulty of 
diagnosis is very great, for the cause of obstruction is too high up to 
be felt. But if we meet with a case in which the pelvis is roomy and 
the pains strong, and yet the head does not descend after an adequate 
time, a full exploration of the cause is essential. For this purpose we 
would naturally put the patient under chloroform, and pass the hand 
sufficiently high. We might then feel the arm in its abnormal posi- 
tion. That was what took place in a case under my own care, in 

1 Selected Obstet. Works, vol. i. 



346 



LABOR. 



which I failed to get the head through the brim with the forceps, and 
eventually delivered by turning. The same course was adopted by 
my friend Mr. Jardine Murray in a similar case. 1 Simpson advises 
that the arm should be brought down so as to convert the case into an 
ordinary hand and head presentation. This, if the arm be above the 
brim, must always be difficult, and I believe the simpler and more 
effective plan is podalic version. A similar displacement may cause 
some difficulty in breech presentations, and after turning (Fig. 125). 
Delay here is easier of diagnosis, since the obstacle to the expulsion 
will at once lead to careful examination. By carrying the body of the 
child well backward, so as to enable the finger to pass behind the 
symphysis pubis and over the shoulder, it will generally be easy to 
liberate the arm. 



Fig. 124. 



Fig. 125. 





Dorsal displacement of the arm. 



Dorsal displacement of the arm in footling 
presentations. (After Barnes.) 



Prolapse of the Umbilical Cord. — It occasionally happens that 
the umbilical cord falls down past the presenting part (Fig. 126), and 
is apt to be pressed between it and the walls of the pelvis. The conse- 
quence is that the foetal circulation is seriously interfered with, and the 
death of the child from asphyxia is a common result. Hence prolapse 
of the funis is a very serious complication of labor in so far as the 
child is concerned. 



i Med. Times and Gaz., 1861 



PRESENTATIONS OF SHOULDER, ETC. 



347 



Frequency. — Fortunately it is not a very frequent occurrence, 
Churchill calculates that out of over 105,000 deliveries it was met 
with once in 240 cases, and Scanzoni once in 264. Its frequency 
varies much under different circumstances, and in different places. 
We find from Churchill's figures a remarkable difference in the pro- 
portiona] number of cases observed in France, England, and Germany 
— viz., 1 in 446£, 1 in 207J, and 1 in 156, respectively. Great as is 
the proportion referred to Germany in these figures, it has been found 
to be exceeded in special districts. Thus Engelmann records 1 cae 
of 94 labors in the Lying-in Hospital at Berlin, and Michaelis 1 in 90 
in that of Kiel. These remarkable differences are at first sight not 
easy to account for. Dr. Simp-en sugg sts, with considerable show of 
probability, that the difference in frequency in England, France, and 

Fig. 126 




Prolapse of the umbilical cord. 

Germany may depend on the varying positions in "which lying-in 
women are placed during labor in each country. In France, where, 
although the patient is laid on her back, the pelvis is kept elevated, 
the complication occurs least frequently ; in England, where she lies 
on her side, more often ; and in Germany, where she is placed on her 
back with her shoulders raised, most often. The special frequency of 
prolapsed funis in certain district-, as in Kiel, is supposed by Engel- 
mann 1 to depend on the prevalence of rickets, and consequently of 
deformed pelvis, which we shall presently see is probably one of the 
most frequent and important causes of the accident. 

Prognosis. — With regard to the danger attending prolapsed funis, 
as far as the mother is concerned, it may be said to be altogether unim- 
portant; but the universal experience of obstetrician- points to the 



1 Amer. Journ. of Obstet., 1S7S-74, vol. vi. pp. 4 



348 LABOR. 

great risk to which the child is subjected. Scanzoni calculates that 45 

per cent, only of the children were saved ; Churchill estimated the 
number at 47 per cent. : thus, under the most favorable circumstances, 
this complication leads to the death of more than half the children. 
Engelmann found that out of 202 vertex presentations only 36 per 

cent, of the children survived. The mortality was not nearly so great 
in other presentations : 68 per cent, of the cases in which the child pre- 
sented with the feet were saved, and 50 per cent, in original shoulder 
presentations. The reason of this remarkable difference is. doubtless. 
that in vertex presentations the head tits the pelvis much more com- 
pletely, and subjects the cord to much greater pressure ; while in other 
presentations the pelvis is less completely tilled, and the interference 
with the circulation in the cord is not so great. Besides, in the latter 
case the complication is detected early, and the necessary treatment 
sooner adopted. 

The foetal mortality is considerably greater in first labors — a result 
to be expected on account of the greater resistance of the soft parts, 
and the consequent prolongation of the labor. 

The causes of prolapse of the funis are any circumstances which 
prevent the presenting part accurately fitting the pelvic brim. Hence 
it is much more frequent in face, breech, or shoulder than in vertex 
presentations, and is relatively more common iu footling and shoulder 
presentations than in any other. Amongst occasional accidental pre- 
disposing causes may be mentioned early rupture of the membranes, 
especially if the amount of liquor amnii be excessive, as the sudden 
escape of the fluid washes down the cord ; undue length of the cord 
itself; or an unusually low placental attachment. Engelmann attaches 
great importance to slight contraction of the pelvis, and states that in 
the Berlin Lying-in Hospital, where accurate measurements of the 
pelvis were taken in all cases, it was almost invariably found to exist. 
The explanation is evident, since one of the first results of pelvic con- 
traction is to prevent the ready engagement of the presenting part in 
the pelvic brim. 

The diagnosis of cord presentation is generally devoid of difficulty ; 
but if the membranes are still unruptured, it may not always be quite 
easy to determine the precise nature of the soft structures felt through 
them, as they recede from the touch. If the pulsations of the cord 
can be felt through the membranes, all difficulty is removed. After 
the membranes are ruptured, there is nothing for which it can well be 
mistaken. 

The important point to determine in such a ca-e is whether the cord 
be pulsating or not: for if pulsations have entirely ceased, the inference 
is that the child is dead, and the case may then be left to Nature without 
further interference. It is of importance, however, to be careful ; for, 
if the examination be made during a pain, the circulation might be 
only temporarily arrested. The examination, therefore, should be 
made during an interval, and a loop of the cord pulled down, if 
necessary, to make ourselves absolutely certain on this point. 

The amount of the prolapse varies much. Sometimes only a knuckle 
of the cord, so small as to escape observation, is engaged between the 



PRESENTATIONS OF S HO I' L PER, ETC. 



349 



pelvis and presenting part Under Buch circumstances the child may 
be sacrificed without any suspicion of danger having arisen. More 
often the amount prolapsed is considerable \ sometimes so as to lie in 
the vagina in a long Loop, or even to protrude altogether beyond the 

vulva. 

Treatment. — In the treatment the great indication is to prevent 
the cord from being unduly pressed on, and all our endeavors must 
have this object in view. If the presentation be detected before the 

full dilatation of the cervix, and when the membranes are unruptured, 
we must try to keep the cord out of the way ; to preserve the mem- 
branes intact as long as possible, since the cord is tolerably protected 
as long as it is surrounded by the liquor amnii : and to secure the 

complete dilatation of the os, so that the presenting part may engage 
rapidly and completely. 

Much may be done at this time by the postural treatment, which 
we chiefly to the ingenuity of Dr. T, Gaillard Thomas, of New 
York, whose writings familiarized the profession with it. although it 
appears that a somewhat similar plan had been occasionally adopted 
previously. Dr. Thomas's method is based on the principle of caus- 
ing the cord to slip back into the uterine cavity by its own weight. 
For this purpose the patient is placed on her hands and knees, with 
the hips elevated, and the shoulders resting on a lower level (Fig. 
127). The cervix is then no longer the most dependent portion of the 

Fig. 127, 




Postural treatment of prolapse of the cord. 



uterus, and the anterior wall of the uterus form- an inclined plane 
down which the cord slips. The success of this manoeuvre is some- 
times very great, but by no means always so. It is most likely to 
succeed when the membranes are unruptured. If. when adopted, the 
cord slip away, and t'n - sufficiently dilated, the membranes may 
be ruptured, and engagement of the head produced by properly 
applied uterine pressure. Sometimes the position i- so irksome that 
it i- impossible to resort to it. Postural treatment i- n<>t even then 
altogether impossible, for by placing the patient on the side opposite 



350. 



LABOR. 



to that of the prolapse, so as to relieve the cord as much as possible 
from pressure, aud at the same time elevating the hips by a pillow, 
it may slip back. Even after the membranes are ruptured, postural 
treatment in one form or another may succeed ; and; as it is simple 
and harmless, it should certainly be always tried. Attempts at repo- 
sition, by one or other method described below, may also occasionally 
be facilitated by trying them when the patient is placed in the knee- 
shoulder position. 

Failing by postural treatment, or in combination with it, it is quite 
legitimate to make an attempt to place the cord beyond the reach of 
dangerous pressure by other methods. Unfortunately reposition is 
too often disappointing, difficult to effect, and very frequently, even 
when apparently successful, shortly followed by a fresh descent of the 
cord. Provided the os be fully dilated and the presenting head 
engaged in the pelvis (for reposition may be said to be hopeless when 
any other part presents), perhaps the best way is to attempt it by the 
hand alone. Probably the simplest and most effectual method is that 
recommended by McClintock and Hardy, who advise that the patient 
should lie on the opposite side to the prolapsed cord, which should 
then be drawn toward the pubes as being the shallowest part of the 
pelvis. Two or three fingers may then be used to 
push the cord past the head, and as high as they 
can reach. They must be kept in the pelvis until 
a pain comes on, and then very gently withdrawn, 
in the hope that the cord may not again prolapse. 
During the pain external pressure may very prop- 
erly be applied to favor descent of the head. This 
manoeuvre may be repeated during several suc- 
cessive pains, and may eventually succeed. The 
attempt to hook the cord over the foetal limbs, or to 
place it in the hollow of the neck, recommended 
in many works, involves so deep an introduction 
of the hand that it is obviously impracticable. 

Various complex instruments have been in- 
vented to aid reposition (Fig. 128), but even if 
we possessed them they are not likely to be at 
hand when the emergency arises. A simple in- 
strument may be improvised out of an ordinary 
male elastic catheter, by passing the two ends of 
a piece of string through it, so as to leave a loop 
emerging from the eye of the catheter. This is 
passed through the loop of prolapsed cord, and 
then fixed in the eye of the catheter by means of 
the stilette. The cord is then pushed up into the 
uterine cavity by the catheter, and liberated by 
withdrawing the stilette. Another simple instru- 
ment may be made by cutting a hole in a piece of 
whalebone. A piece of tape is then passed through 
the loop of the cord and the ends threaded through the eye cut in the 
whalebone. By tightening the tape the whalebone is held in close 




Braun's apparatus for 
replacing the cord. 



PROLONGED AND PRECIPITATE LABORS. 351 

apposition to the 4 cord, and the whole is passed as high as possible into 
the uterine cavity. The tape can easily be Liberated by pulling one 

end. It' preferred, the cord can be tied to the whalebone, which is 
left in ulcro until the child is horn. Nothing need be said as to the 
various other methods adopted for keeping up the cord, such as the 

insertion of pieces of sponge, or tying the cord in a bag of soft leather, 
since they are generally admitted to be quite useless. 

It only too often happens that all endeavors at reposition fail. The 
subsequent treatment must then be guided by the circumstances of the 
ease. If the pelvis be roomy, and the pains strong, especially in a 
multipara, we may often deem it advisable to leave the case to Nature, 
in the hope that the head may be pushed through before pressure on 
the cord has had time to prove fatal to the child. Under such circum- 
stances the patient should be urged to bear down, and the descent of the 
head be promoted by uterine pressure, so as to get the second stage 
completed as soon as possible. If the head be within easy reach, the 
application of the forceps is quite justifiable, since delay must neces- 
sarily involve the death of the child. During this time the cord should 
be placed, if possible, opposite one or the other sacro-iliac synchon- 
drosis according to the position of the head, as being the part of the 
pelvis where there is most room, and pressure would consequently 
be least prejudicial. If we have to do with a case in which the head 
has not descended into the pelvis, and postural treatment and re- 
position have both failed, provided the os be fully dilated, and other 
circumstances be favorable, turning would undoubtedly offer the best 
chance to the child. This treatment is strongly advocated by Engel- 
mann, who found that 70 per cent, of the children delivered in this 
way were saved. There can be no question that, so far as the inter- 
ests of the child are concerned, it is, under the circumstances indicated, 
by far the best expedient. Turning, however, is by no means always 
devoid of a certain risk to the mother, and the performance of the 
operation, in any particular case, must be left to the judgment of the 
practitioner. A fully dilated os, with membranes unruptured, so that 
version could be performed by the combined method without the 
introduction of the hand into the uterus, would be unquestionably the 
most favorable state. If it be not deemed proper to resort to it, all 
that can be done is to endeavor to save the cord from pressure as much 
as possible, by one or another of the methods already mentioned. 



CHAPTEE IX. 

PROLONGED AND PRECIPITATE LABORS. 

Among the difficulties connected with parturition there are none of 
more frequent occurrence, and none requiring more thorough knowl- 
edge of the physiology and pathology of labor, than those arising from 



352 LABOR. 

deficient or irregular action of the expulsive powers. The importance 
of studying this class of labors will be seen when w r e consider the 
numerous and very diverse causes which produce them. 

Evil Effects of Prolonged Labor. — That the mere prolongation 
of labor is in itself a serious thing, is becoming daily more and more 
an acknowledged axiom of midwifery practice ; and that this is so is 
evident when w r e contrast the statistical returns of such institutions as 
the Rotunda Lying-in Hospital of late years, with those wdrich were 
published some twenty or thirty years ago. It may be fairly assumed 
that the practice of the distinguished heads of that well-known school 
represents the most advanced and scientific opinions of the day. When 
we find that, less than thirty years ago, forceps were not used more 
than once in 310 labors, while, according to the report for 1873, the 
late master applied them once in 8 labors, it is apparent how great is 
the change which has taken place. 

Labor may be prolonged from an immense number of causes, the 
principal of which will require separate study. Some depend simply 
on defective or irregular action of the uterus ; others act by opposing 
the expulsion of the child, as, for example, undue rigidity of the par- 
turient passages, tumors, bony deformity, and the like. Whatever the 
source of delay, a train of formidable symptoms is developed which 
are fraught with peril both to the mother and the child. As regards 
the mother, they vary much in degree and in the rapidity with which 
they become established. In many cases, in which the action of the 
uterus is slight, it may be long before serious results follow ; while in 
others, in which a strongly-acting organ is exhausting itself in futile 
endeavors to overcome an obstacle, the worst signs of protraction may 
come on with comparative rapidity. 

The stage of labor in which delay occurs has a marked effect 
in the production of untoward symptoms. It is a well-established 
fact that prolongation is of comparatively small consequence to either 
the mother or child in the first stage, when the membranes are still 
intact, and when the soft parts of the mother, as well as the body of 
the child, are protected by the liquor amnii from injurious pressure ; 
whereas if the membranes have ruptured, prolongation becomes of the 
utmost importance to both as soon as the head has entered the pelvis, 
when the uterus is strongly excited by reflex stimulation, when the 
maternal soft parts are exposed to continuous pressure, and Avhen the 
tightly contracted uterus presses firmly on the foetus and obstructs the 
placental circulation. It is in reference to the latter class of cases that 
the change of practice, already alluded to, has taken place, with the 
most beneficial results both to mother and child. 

It must not be assumed, however, that prolongation of labor is 
never of any consequence until the second stage has commenced. The 
fallacy of such an opinion was long ago shown by Simpson, who 
proved in the most conclusive way, that both the maternal and foetal 
mortality were greatly increased in proportion to the entire length of 
the labor ; and all practical accoucheurs are familiar with cases in which 
symptoms of gravity have arisen before the first stage is concluded. 
Still, relatively speaking, the opinion indicated is undoubtedly correct. 



PROLONGED AND PRECIPITATE LABORS. 353 

In the present chapter we have to do only with those causes of 
delay connected with the expulsive powers, Inasmuch, however, as 
the injurious effects of protraction are similar in kind whatever be 
the cause, it will save needless repetition ii we consider, once for all, 

the train of symptoms that arise whenever labor is unduly prolonged. 
Delay in the First Stage is Rarely Serious. — As long as the 
delay is in the first stage only, with rare exceptions, no symptoms of 

real gravity arise for a length of time; it may be even for days. 
There is often, however, a partial cessation of the pains, which, in 
consequence of temporary exhaustion of nervous force, may even 
entirely disappear for many consecutive hours. Under such circum- 
stances, after a period of rest, either natural or produced by suitable 
sedatives, they recur with renewed vigor. 

Symptoms of Protraction in the Second Stage. — A similar 
temporary cessation of the pains may often be observed after the head 
has passed through the os uteri, to be also followed by renewed vigor- 
ous action after rest. But now any such irregularity must be much 
more anxiously watched. In the majority of cases any marked alter- 
ation in the force and frequency of the pains at this period indicates 
a much more serious form of delay, which in no long time is accom- 
panied by grave general symptoms. The pulse begius to rise, the skin 
to become hot and dry, the patient to be restless and irritable. The 
longer the delay, and the more violent the efforts of the uterus to 
overcome the obstacle, the more serious does the state of the patient 
become. The tongue is loaded with fur, and iu the worst cases dry 
and black ; nausea and vomiting often become marked ; the vagina 
feels hot and dry, the ordinary abundant mucous secretion being 
absent ; in severe cases it may be much swollen, and if the presenting 
part be firmly impacted, a slough may even form. Should the patient 
still remain undelivered, all these symptoms become greatly intensi- 
fied ; the vomiting is incessant, the pulse is rapid and almost imper- 
ceptible, low muttering delirium supervenes, and the patient eventually 
dies with all the worst indications of profound irritation and exhaustion. 

So formidable a train of symptoms, or even the slighter degrees of 
them, should never occur iu the practice of the skilled obstetrician j 
and it is precisely because a more scientific knowledge of the process 
of parturition has taught the lessou that, under such circumstances, 
prevention is better than cure, that earlier interference lias become so 
much more the rule. 

Those who taught that nothing should be done until Nature had 
had every possible chance of effecting delivery, and who, therefore, 
allowed their patients to drag ou through many weary hours of labor, 
at the expense of great exhaustion to themselves, and imminent risk 
to their offspring, made much capital out of the time-houored maxim 
that " meddlesome midwifery is bad." When this proverb is applied 
to restrain the rash interference of the ignorant, it is of undeniable 
value ; but when it is quoted to prevent the scientific action of the 
experienced, who know T precisely when and why to interfere, and who 
have acquired the indispensable mechanical skill, it is sadly mis- 
applied. 

23 



354 LABOR. 

State of the Uterus in Protracted Labor. — The nature of the 
pains and the state of the uterus, in cases of protracted labor, are 
peculiarly worthy of study, aud have been very clearly pointed out 
by Dr. Braxtou Hicks. 1 He shows that, when the pains have appar- 
ently fallen off and become few and feeble, or have entirely ceased, 
the uterus is in a state of continuous or tonic contraction, and that the 
irritation resulting from this is the chief cause of the more marked 
symptoms of powerless labor. If, in a case of the kind, the uterus 
be examined by palpation, it will be found firmly contracted between 
the pains. The correctness of this observation is beyond question, 
and it will, no doubt, often be an important guide in treatment. 
Under such circumstances instrumental interference is imperatively 
demanded. 

Causes. — In considering the causes of protracted labor, it will be 
well first to discuss those which affect the expulsive powers alone, 
leaving those depending on morbid states of the passages for future 
consideration ; bearing in mind, however, that the results, as regards 
both the mother and the child, are identical, whatever may be the 
cause of delay. 

The general constitutional state of the patient may materially in- 
fluence the force and efficiency of the pains. Thus it not unfrequently 
happens that they are feeble and ineffective in women of very weak 
constitution, or who are much exhausted by debilitating disease. 
Cazeaux pointed out that the effects of such general conditions are 
often more than counterbalanced by flaccidity and want of resistance 
of the tissues, so that there is less obstacle to the passage of the child. 
Thus, in phthisical patients reduced to the last stage of exhaustion, 
labor is not unfrequently surprisingly easy. 

Long residence in tropical climates causes uterine inertia, in conse- 
quence of the enfeebled nervous power it produces. It is a common 
observation that European residents in India are peculiarly apt to 
suffer from post-partum hemorrhage from this cause. The general 
mode of life of patients has an unquestionable effect ; and it is certain 
that deficient and irregular uterine action is more common in women 
of the higher ranks of society, who lead luxurious, enervating lives, 
than in women whose habits are of a more healthy character. 

Tyler Smith lays much stress on frequent childbearing as a cause 
of inertia, pointing out that a uterus which has been very frequently 
subjected to the changes connected with pregnancy, is unlikely to be 
in a typically normal condition. It is doubtful, however, whether the 
uterus of a perfectly healthy woman is affected in this way ; certainly, 
if childbearing had undermined her general health, the labors are 
likely to be modified also. 

Age has a decided effect. In the very young the pains are apt to be 
irregular, on account of imperfect development of the uterine muscles. 
Labor taking place for the first time in women advanced in life is also 
apt to be tedious, but not by any means so invariably as is generally 
believed. The apprehensions of such patients are often agreeably 

i Obst. Trans., 1867, vol. ix. p. 207. 



PROLONGED AND PRECIPITATE LABORS. 355 

falsified, and where delay does occur, it is probably more ofter referable 
to rigidity and toughness of the parturient passages than to feebleness 
of the pains. 

Morbid states of the primse vise frequently cause irregular, painful, 
and feeble contractions. A loaded state of the rectum has a remarkable 
influence, as evidenced by the sudden and distinct change in the char- 
acter of the labor which often follows the use of suitable remedies. 
Undue distention of the bladder may act in the same way, more espe- 
cially in the second stage. When the urine has been allowed to accu- 
mulate unduly, the contraction of the accessory muscles of parturition 
often causes such intense suffering, by compressing the distended viscus, 
that the patient is absolutely unable to bear down. Hence the labor 
is carried on by uterine contractions alone, slowly, and at the expense 
of much suffering. A similar interference with the action of the 
accessory muscles is often produced by other causes. Thus if labor 
comes on when the patient is suffering from bronchitis or other chest 
disease, she may be quite unable to fix the chest by a deep inspiration, 
and the diaphragm and other accessory muscles cannot act. In the 
same way they may be prevented from acting when the abdomen is 
occupied by an ovarian tumor, or by ascitic fluid. 

Mental conditions have a very marked effect. This is so commonly 
observed that it is familiar to the merest beginner in midwifery prac- 
tice. The fact that the pains often diminish temporarily on the 
entrance of the accoucheur is known to every nurse ; and so also undue 
excitement, the presence of too many people in the room, overmuch 
talking, have often the same prejudicial effect. Depression of mind, 
as in unmarried women, and fear and despondency in women who have 
looked forward with apprehension to the labor, are also common causes 
of irregular and defective action. 

Undue distention of the uterus from an excessive amount of liquor 
amnii not unfrequently retards the first stage, by preventing the uterus 
from contracting efficiently. When this exists, the pains are feeble 
and have little effect in dilating the cervix beyond a certain degree. 
This cause may be suspected when undue protraction of the first stage 
is associated with an unusually large size and marked fluctuation of 
the uterine tumor, through which the foetal limbs cannot be made out 
on palpation. On vaginal examination the lower segment of the 
uterus will be found to be very rounded and prominent, while the 
bag of membranes will not bulge through the os during the acme of 
the pain. 

A somewhat similar cause is undue obliquity of the uterus, which 
prevents the pains acting to the best mechanical advantage, and often 
retards the entry of the presenting part into the brim. The most 
common variety is anteversion, resulting from undue laxity of the 
abdominal parietes, which is especially found in women who have 
borne many children. Sometimes this is so excessive that the fundus 
lies oves the pubes, and even projects downward toward the patient's 
knees. The consequence is, that, when labor sets in, unless corrective 
means be taken, the pains force the head against the sacrum, instead 
of directing it into the axis of the pelvic inlet. Another common 



356 LABOR. 

deviation is lateral obliquity, a certain degree of which exists in almost 
all cases, but sometimes it occurs to an excessive degree. Either of 
these states can readily be detected by palpation and vaginal examina- 
tion combined. In the former the os may be so high up, and tilted so 
far backward, that it may be at first difficult to reach it at all. 

Irregular and Spasmodic Pains. — Besides being feeble, the uterine 
contractions, especially in the first stage, are often irregular and spas- 
modic, intensely painful, but producing little or no effect on the 
progress of the labor. This kind of case has been already alluded to 
in treating of the use of anaesthetics (p. 308), and is very common in 
highly nervous and emotioual women of the upper classes. In such 
cases cocaine has been of late used as a local application with decided 
benefit. It appears to act by deadening the pain resulting from the 
stretching of the nerves of the cervix, or from slight cervical lacera- 
tions. It has no effect in relieving the suffering caused by uterine 
contraction. 1 It has been applied by means of a cotton-wool tampon 
steeped in a 2 per cent, solution, and placed against the os. A much 
better way of using it is by " Moore's cones" 3 made with cacao-butter, 
one of which is placed on the examining finger like a thimble, and 
inserted within the os, where it rapidly melts. Antipyrine has been 
frequently used in this kind of labor as a uterine sedative, but its 
beneficial effects appear to be doubtful. Auvard and Lefebvre, 3 who 
have carefully studied and reported cases, come to the conclusion that 
it cannot be compared in efficacy with chloral, although occasionally 
useful. It may be given in a dose of fifteen grains, repeated in two 
hours. Such irregular contractions do not necessarily depend on 
mental causes alone, and they often follow conditions producing irrita- 
tion, such as loaded bowels, too early rupture of the membranes, and 
the like. Dr. Trenholme, of Montreal, 4 believes that such irregular 
pains most frequently depend on abnormal adhesions between the 
decidua and the uterine Avails, which interfere with the proper dilata- 
tion of the os, and he has related some interesting cases in support of 
this theory. 

Treatment. — The mere enumeration of these various causes of pro- 
tracted labor will indicate the treatment required. Some of them, 
such as the constitutional state of the patient, age, or mental emotion, 
it is, of course, beyond the power of the practitioner to influence or 
modify; but in every case of feeble or irregular uterine action, a careful 
investigation should be made with the view of seeing if any removable 
cause exist. For example, the effect of a large enema, when we sus- 
pect the existence of a loaded rectum, is often very remarkable ; the 
pains frequently almost immediately changing in character, and a pre- 
viously lingering labor being rapidly terminated. 

Excessive distention of the uterus can only be treated by artificial 
evacuation of the liquor amnii ; and after this is done, the character of 
the pains often rapidly changes. This expedient is indeed often of 
considerable value in cases in which the cervix has dilated to a cer- 

i "The Value of Cocaine iu Obstetrics," by John Phillips, M.A., M.D. Lancet, Nov. 26, 1887. 

2 Brit. Med. Journ., 1885, vol. ii. p. 1140. 

a Arch, de Tocol., 1388, p. 649, and 1889, p. 505. 

4 Obst. Trans., 1873, vol. xiv. p. 231. 



PROLONGED AND PRECIPITATE LABORS. 357 

tain extent, but in which no further progress is made, especially if the 
bag of membranes does not protrude through the os during the pains, 
and the cervix itself is soft, and apparently readily dilatable. Under 
such circumstance's, rupture' of the membranes, even before the os is 
fully dilated, is often very useful. 

If we have reason to suspect morbid adhesions between the mem- 
branes and the uterine Malls, an endeavor must be made to separate 
them by sweeping the finger or a flexible catheter around the internal 
margin of the os, or puncturing the sac. The former expedient has 
been advocated by Dr. Inglis, 1 as a means of increasing the pains when 
the first stage is very tedious, and I have often practised it with marked 
success. Trenholme's observation affords a rationale of its action. 
The manoeuvre itself is easily accomplished, and, provided the os be 
not very high in the pelvis, does not give any pain or discomfort to 
the patient. 

Attention should always be paid to remedying any deviations of the 
uterus from its proper axis. If this be lateral, the proper course to 
pursue is to make the patient lie on the opposite side to that toward 
which the organ is pointing. In the more common anterior deviation 
she should lie on her back, so that the uterus may gravitate toward 
the spine, and a firm abdominal bandage should be applied. This 
prevents the organ from falling forward, while its pressure stimu- 
lates the muscular fibres to increased action ; hence it is often very 
serviceable when the pains are feeble, even if there be no antever- 
sion. 

In a frequent class of cases, especially in the first stage, the pains 
diminish in force and frequency from fatigue, and the indication then 
is to give a temporary rest, after which they recommence with renewed 
vigor. Hence an opiate, such as twenty minims of Battley's solution, 
which often acts quickest when given in the form of enema, is fre- 
quently of the greatest possible value. If this secure a few hours' 
sleep the patient will generally awake much refreshed and invigorated. 
It is important to distinguish this variety of arrested paiu from that 
dependent on actual exhaustion ; and this can be done by attention to 
the general condition of the patient, and especially by observing that 
the uterus is soft and flaccid in the intervals between the pains, and 
that there is uone of the tonic contraction indicated by persistent hard- 
ness of the uterine parietes. When the pains are irregular, spasmodic, 
and excessively painful, without producing any real effect, opiates are 
also of great service ; and it is under such circumstances that chloral 
is especially valuable. 

Oxytocic Remedies. — Still a large number of cases will arise in 
which the absence of all removable causes has been ascertained, and in 
which the pains are feeble and ineffective. AVe must now proceed to 
discuss their management. The fault being the want of sufficient con- 
traction, the first indication is to increase the force of the pains. Here 
the so-called oxytocia remedies come into action ; and, although a large 
number of these have been used from time to time, such as borax, 

1 Sydenham Society's Year-book, 1367, p. 399. 



358 LABOR. 

cinnamon, quinine, and galvanism, practically the only one in which 
reliance is generally placed is the ergot of rye. This has long been 
the favorite remedy for deficient uterine action, and it is a powerful 
stimulant of the uterine fibres. It has, however, very serious disad- 
vantages, and it is very questionable whether the risks to both mother 
and child do not more than counterbalance any advantages attending 
its use. The ergot is given in doses of fifteen or twenty grains of the 
freshly powdered drug infused in warm water, or in the more con- 
venient form of the liquid extract in doses of from twenty to thirty 
minims, or, still better, in the form of ergotine injected hypodermi- 
cally, three to four minims of the hypodermic solution beiug used for 
the purpose. In about fifteen minutes after its administration the 
pains generally increase greatly in force and frequency, and if the 
head be low in the pelvis, and if the soft parts offer no resistance, the 
labor may be rapidly terminated. 

AVere its use always followed by this effect there would be little or 
no objection to its administration. The pains, however, are different 
from those of natural labor, being strong, persistent, and constant. Its 
effect, indeed, is to produce that very state of tonic and persistent 
uterine contraction which has already been pointed out as one of the 
chief dangers of protracted labor. Hence, if from any cause the exhibi- 
tion of the drug be not followed by rapid delivery, a condition is pro- 
duced which is serious to the mother, and which is extremely perilous 
to the child, on account of the tonic contraction of the muscular fibres 
obstructing the utero-placental circulation. Dr. Hardy found that 
soon the foetal pulsations fall to 100, and, if delivery be long delayed, 
they commence to intermit. He also observed that when this occurred 
the child was always born dead, and found that the number of still- 
born children after ergot has been exhibited was very large ; for out 
of thirty cases in which he gave it in tedious labor, only ten of the 
children were born alive. Xor is its use by any means free from 
danger to the mother ; a not inconsiderable number of cases of rupture 
of the uterus have been attributed to its incautious use. Hence, if it 
is to be given at all, it is obvious that it must be with strict limita- 
tions, and after careful consideration. It is worthy of note that in the 
Rotunda Hospital in Dublin, the use of ergot as an oxytocic before 
delivery has been prohibited by the present master. 

The cardinal point to remember is that it is absolutely contra-indi- 
cated unless the absence of all obstacles to rapid delivery has been 
ascertained. Hence, it is only allowable when the first stage is over, 
and the os fully dilated ; Avhen the experience of former labors has 
proved the pelvis to be of ample size ; and when the perineum is soft 
and dilatable. Perhaps, as has been suggested, the administration of 
small doses of from five to ten minims of the liquid extract every ten 
minutes, until more energetic action sets in, might obviate some of 
these risks. 

The use of quinine as an oxytocic deserves much more attention 
than it has generally received. I frequently employ it in lingering 
labor with marked benefit, and it does not seem to have any of the 
bad effects of ergot. According to the observations of Dr. Albert H. 



PROLONGED AND PRECIPITATE LABORS. 359 

Smith, in forty-two cases of parturition, it presented the following 

peculiar characteristics : 

It has no power in itself to excite uterine contractions, but simply 
acts as a general stimulant and promoter of vital energy and func- 
tional activity. Dr. R. Doyle, of Trinidad, recently writes to point 
out that quinine given in malarial fever is constantly observed to pro- 
duce uterine contractions and abortion. 1 

In normal labor at full term, its administration in a dose of fifteen 
grains is usually followed in as many minutes by a decided increase in 
the force and frequency of the uterine contractions, changing in some 
instances a tedious, exhausting labor into one of rapid energy, ad- 
vancing to an early completion. 

It promotes the permanent tonic contraction of the uterus, after the 
expulsion of the placenta ; women that had flooded in former labors 
escaping entirely, there not having been an instance of post-partuni 
hemorrhage in the Avhole forty- two cases. 

It also diminishes the lochial flow where it had been excessive in 
former labors, the change being remarked upon by the patients, and 
consequently lessens the severity of the after-pains. 

Cinchonism is very rarely observed as an effect of large doses in 
parturient women. 2 

Use of the Faradic Current. — The faradic current applied on 
either side of the uterine tumor, midway between the anterior-superior 
spine of the ilium and the umbilicus, has recently been strongly recom- 
mended by Dr. Kilner, 3 not only as a means of increasing uterine 
action, but of alleviating the sufferings of childbirth. I have tried it 
in several cases, but am not satisfied as to its possessing the properties 
attributed to it. 

If we had no other means of increasing defective uterine contractions 
at our disposal, and if the choice lay only between the use of ergot and 
instrumental delivery, there might not be so much objection to a cau- 
tious use of the drug in suitable cases. "We have, however, a means of 
increasing the force of the uterine contractions so much more manage- 
able, and so much more resembling the natural process, that I believe 
it to be destined to entirely supersede the administration of ergot. 
This is the application of manual pressure to the uterus through the 
abdomen, an expedient that has of late years been much used in Ger- 
many, and has begun to be employed in English practice. I believe, 
therefore, that ergot should be chiefly used for the purpose of exciting 
uterine contraction after delivery, when its peculiar property of pro- 
moting tonic contraction is so valuable, and that it should rarely, if at 
all, be employed before the birth of the child. 

The systematic use of uterine pressure as an oxytocic was first promi- 
nently brought under the notice of the profession by Kristeller, under 
the name of expressio foetus, although it has been used in various 
forms from time immemorial. Albucasis, for example, was clearly 
acquainted with its use, and referred to it in the following terms: 

1 Brit. Med. Journ., 1K89. vol. ii. p. 689. 

2 Trans. Coll. Phys., Philadelphia, 1875, p. 183. 

3 Obst. Trans, for 1884. vol. xxvi. p. 93. 



360 LABOR. 

" Cum ergo vides ista signa, tunc oportet, ut comprimatur uterus ejus ut 
descendat embryo velociter." It was known to Guillemeau, who says: 
" Quelquefois j'ai ordonne a, Tune des dites femmes de presser fort 
doucement du plat de la main, les parties superieures du ventre en 
ramenant l'enfant, petit a petit, en bas; telle mediocre compression 
facilitait l'accouchement en faisant que les tranchees se supportaient 
plus aisement et facilement. 1 There are some curious obstetric customs 
among various nations, which probably arose from a recognition of its 
value ; as, for example, the mode of delivery adopted among the Kal- 
mucks, where the patient sits at the foot of the bed, while a woman, 
seated behind her, seizes her around the waist and squeezes the uterus 
during the pains. Amongst the Japanese, Siamese, North American 
Indians, and many other nations, pressure, applied in various ways, is 
habitually used. [ 2 ] 

Kristeller maintains that it is possible to effect the complete expul- 
sion of the child by properly applied pressure, even when the pains are 
entirely absent. Strauge as this may appear to those who are not 
familiar with the effects of pressure, I believe that, under exceptional 
circumstances, when the pelvis is very capacious, and the soft parts 
offer but slight resistance, it can be done. I have delivered in this 
way a patient whose friends would not permit me to apply the forceps, 
when I could not recognize the existence of any uterine contraction at 
all, the foetus being literally squeezed out of the uterus. It is not, 
however, as replacing absent pains, but as a means of intensifying and 
prolonging the effects of deficient and feeble ones, that pressure finds 
its best application. 

Its effects are often very remarkable, especially in women of slight 
build, where there is but little adipose tissue in the abdomiual walls, 
and not much resistance in the pelvic tissues. If the finger be placed 
on the head while pressure is applied to the uterus, a very marked 
descent can readily be felt, and not infrequently two or three applica- 
tions will force the head on to the perineum. There are, however, 
certain conditions in which it is inapplicable, and the existence of which 
should contra-indicate its use. Thus if the uterus seem unusually 
tender on pressure, and, a fortiori, if the tonic contraction of exhaus- 
tion be present, it is inadmissible. So also if there be any obstruction 
to rapid delivery, either from narrowing of the pelvis or rigidity of 
the soft parts, it should not be used. The cases suitable for its appli- 
cation are those in which the head or breech is in the pelvic cavity, 
and the delay is simply due to a want of sufficiently strong expulsive 
action. 

It may be applied in two ways. The better plan is to place the 
patient on her back at the edge of the bed, and spread the palms of 
the hands on either side of the fundus and body of the uterus, and, 
when a pain commences, to make firm pressure during its continuance 
downward and backward in the direction of the pelvic inlet. As the 
contraction passes off the pressure is relaxed, and again resumed when 
a fresh pain begins. In this way each pain is greatly intensified, and 



i L'Obstetrique aux XVII. et XVIII. Siecles. Paris, 1892. 
[2 Labor Among Primitive Peoples. Geo. J. Engelmann, St. Louis, 



18S3. 8vo. pp. 227.— Ed.] 



PROLONGED AND PRECIPITATE LABORS. 861 

its effect on the progress of the foetus much increased. It is not 
essential that the patient should lie 1 on her back. A useful, although 
not so great, amount of pressure can be applied when she is Lying in 
the ordinary obstetric position on her left side, the left hand being 
spread out over the fundus, leaving the right free to Match the progress 
of the presenting partjoer vaginam. 

Special Value of Uterine Pressure. — The special value of this 
method of treating ineffective pains is, that the amount and frequency 
of the pressure are completely within the control of the practitioner, 
and are capable of being regulated to a nicety in accordance with the 
requirements of each particular case. It has the peculiar advantage 
of closely imitating the natural means of delivery, and of being abso- 
lutely without risk to the child ; nor is there any reason to think that 
it is capable of injuring the mother. At least I may safely say that, 
out of the large number of cases in which I have used it, I have never 
seen one in which I had the least reason to think that it had proved 
hurtful. Of course, it is essential not to use undue roughness ; firm 
and even strong pressure may be employed, but that can be done 
without being rough, and, as its application is always intermittent, 
there is no time for it to inflict any injury on the uterine tissues. 

Pressure is specially valuable when it is desirable to intensify 
feeble pains. It may be serviceably employed when the pains are 
altogether absent, to imitate and replace them, provided there be 
nothing but the absence of a vis a tergo to prevent speedy delivery. 
In such cases an endeavor should be made to imitate the pains as 
closely as possible, by applying the pressure at intervals of four or five 
minutes, and entirely relaxing it after it has been applied for a few 
seconds. 

Instrumental Delivery. — When all these means fail we have then 
left the resource of instrumental aid, and we have now to consider the 
indications for the use of the forceps under such circumstances. It 
has been already pointed out that professional opinion on this point 
has been undergoing a marked change ; and that it is now recognized 
as an axiom by the most experienced teachers that, when we are once 
convinced that the natural efforts are failing, and are unlikely to effect 
delivery, except at the cost of long delay, it is far better to interfere 
soon rather than late, and thus prevent the occurrence of the serious 
symptoms accompanying protracted labor. The recent important 
debate on the use of the forceps at the Obstetrical Society of London 
remarkably illustrated these statements, for while there was much 
difference of opinion as to the advisability of applying the forceps 
when the head was high in the pelvis, a class of cases not now under 
consideration, it was very generally admitted that the modern teaching 
was based on correct scientific grounds. This is, of course, directly 
opposed to the view so long taught in our standard works, in which 
instrumental interference was strictly prohibited unless all hope of 
natural delivery was at an end ; and in which the commencement at 
least, if not the complete establishment, of symptoms of exhaustion, 
was considered to be the only justification for the application of the 
forceps in lingering labor. 



362 LABOR. 

The reasons which led the late distinguished master of the Rotunda 
Hospital to a more frequent use of the forceps are so well expressed in 
his report for 1872, that I venture to quote them, as the best justifica- 
tion for a practice that many practitioners of the older school will, no 
doubt, be inclined to condemn as rash and hazardous. He says i 1 " Our 
established rule is that so long as Nature is able to effect its purpose 
without prejudice to the constitution of the patient, danger to the soft 
parts, or the life of the child, we are in duty bound to allow the labor 
to proceed ; but as soon as we find the natural efforts are beginning to 
fail, and after having tried the milder means for relaxing the parts or 
stimulating the uterus to increased action, and the desired effects not 
being produced, we consider we are in duty bound to adopt still 
prompter measures, and by our timely assistance relieve the sufferer 
from her distress and her offspring from an imminent death. Why, 
may I ask, should we permit a fellow-creature to undergo hours of 
torture when we have the means of relieving her within our reach ? 
Why should she be allowed to waste her strength, and incur the risks 
consequent upon long pressure of the head on the soft parts, the ten- 
dency to inflammation and sloughing, or the danger of rupture, not to 
speak of the poisonous miasma which emanates from an inflammatory 
state of the passages, the result of tedious labor, and which is one of 
the fertile causes of puerperal fever and all its direful effects, attributed 
by some to the influence of being confined in a large maternity, and 
not to its proper source, i. e., the labor being allowed to continue till 
inflammatory symptoms appear ? The more we consider the benefits 
of timely interference, and the good results which follow it, the more 
are we induced to pursue the system we have adopted, and to inculcate 
to those we are instructing the advantages to be gained by such practice, 
both in saving the life of the child as well as securing the greater safety 
of the mother." It would be impossible to put the matter in a stronger 
or clearer light, and I feel confident that these views will be indorsed 
by all who have adopted the more modern practice. 

Effect of Early Interference on the Infantile Mortality. — In the 
first edition of this work I used the statistics of Dr. Hamilton, of 
Falkirk, and other modern writers, as proving that a more frequent 
use of the forceps than had been customary diminished in a remarkable 
degree the infantile mortality. Dr. Galabin 2 has recently published an 
admirable paper on this subject, in which, by a careful criticism of 
these figures, he has, I think, proved that the conclusions drawn from 
them are open to doubt, and that the saving of infantile life following 
more frequent forceps delivery is by no means so great as I had sup- 
posed. Dr. Eoper, in his remarks in the recent debate in the Obstet- 
rical Society, brought forward some strong arguments in support of 
the same view. This, however, does not in any way touch the main 
points at issue referred to in the preceding paragraph. 

Possible Dangers attending* the Use of the Forceps. — It is, of 
course, right that we should consider the opposite point of view, and 
reflect on the disadvantages which may attend the interference advo- 

1 Fourth Clinical Report of the Rotunda Lying-in Hospital, Dublin, for the year ending 1872. 

2 Obstet. Journ., 1877-78, vol. v. p. 561. 



PROLONGED AND PRECIPITATE LABORS. 363 

cated. Here I should point out that J am now writing only of the use 
of the forceps in simple inertia, when the head is low in the pelvic 
cavity, and when all that is wanted is a slight vis a f route to supplement 
the deficient vis dt tergo. The use of the instrument wheu the head is 
arrested high in the pelvis, or in eases of deformity, or before the os 
uteri is completely expanded, is an entirely different and much more 
serious matter, and does not enter into the present discussion. The 
chief question to decide is, if there he sufficient risk to the mother to 
counterbalance that of delay. It will, of course, be conceded by all 
that the forceps in the hands of a coarse, bungling, and ignorant prac- 
titioner, who has not studied the proper mode of operating, may easily 
inflict serious damage. The possibility of inflicting injury in this way 
should act as a warning to every obstetrician to make himself thor- 
oughly acquainted with the proper mode of using the instrument, and 
to acquire the manual skill which practice and the study of the 
mechanism of delivery will alone give ; but it can hardly be used as 
an argument against its use. If that were admitted, surgical inter- 
ference of any kind would be tabooed, since there is none that ignorance 
and incapacity might not render dangerous. 

Assuming, therefore, that the practitioner is able to apply the forceps 
skilfully, is there any inherent danger in its use ? I think all ayIio 
dispassionately consider the question must admit that, in the class of 
cases alluded to, the operation is so simple that its disadvantages can- 
not for a moment be weighed against those attending protraction and 
its consequences. Against this conclusion statistics may possibly be 
quoted, such as those of Churchill, who estimated that one in twenty 
mothers delivered by forceps in British practice was lost.f 1 ] But 
the fallacy of such figures is apparent on the slightest consideration ; 
and by no one has this been more conclusively shown than by Drs. 
Hicks and Phillips in their paper on tables of mortality after obstetric 
operations, 2 where it is proved in the clearest manner that such results 
are due not to the treatment, but rather to the fact that the treatment 
was so long delayed. 

It is quite impossible to lay down any precise rule as to when the 
forceps should be used in uterine inertia. Each case must be treated 
ou its own merits, and after a careful estimate of the effects of the 
pains. The rules generally taught were that the head should be 
allowed to rest at or near the perineum for a number of hours, and 
that interference was contra-indicated if the slightest progress were 
being made. It is needless to say that both of these rules are incom- 
patible Avith the views I have been inculcating, and that any rule 
based upon the length of time the second stage of labor has lasted 
must necessarily be misleading. What has to be done, I conceive, is 
to watch the progress of the case anxiously after the second stage has 
fairly commenced, and to be guided by an estimate of the advance that 
is being made and the character of the pains, bearing in mind that the 
risk to the mother, and still more to the child, increases seriously with 

[ l Churchill's statistics were collected in so unreliable a way, that I have long since ceased to 
put any faith in them.— Ed. ] 
2 Obs't. Trans., 1872, vol. xiii. p. 55. 



364 LABOK. 

each hour that elapses. If we find the progress slow and unsatisfac- 
tory, the pains nagging and insufficient, and incapable of being 
intensified by the means indicated, then, provided the head be low in 
the pelvis, it is better to assist at once by the forceps, rather than to 
wait until we are driven to do so by the state of the patient. 1 

1 It may, perhaps, be of interest in connection with this important topic in practical midwifery 
if I reprint a letter I published some years ago in the Medical Times and Gazette. An historical 
case, such as that of which it treats, will better illustrate the evil effects that may follow un- 
necessary delay than any amount of argument. It seems to me impossible to read the details of 
the delivery it describes "without being forcibly struck with the disastrous results which followed 
the practice adopted, which, however, was strictly in accordance with that considered correct, 
up to a quite recent date, by the highest obstetric authorities. 

On the Death of the Princess Charlotte of Wales. 
(To the Editor of the Medical Times and Gazette.) 

Sir: The letter of your correspondent, "An Old Accoucheur," regarding the death of the 
Princess Charlotte, raises a question of great interest — viz., whether the fatal result might have 
been averted under other treatment? The history of the case is most instructive, and I think a 
careful consideration of it leaves little room to doubt that, though the management of the labor 
was quite in accordance with the teaching of the day, it was entirely opposed to that of modern 
obstetric science. The following account of the labor may interest your readers, and will probably 
be new to most of them. It is contained in a letter from Dr. John Sims to the late Dr. Joseph 
Clarke, of Dublin : 

" London, November 15, 1817. 

"My dear Sir : I do not wonder at your wishing to have a direct statement of the labor of her 
Royal Highness the Princess Cnarlotte, the fatal issue of which has involved the whole nation in 
distress. You must excuse my being very concise, as I have been, and am. very much hurried. 
I take the opportunity of writing this in a lying-in chamber. Her Royal Highness's labor com- 
menced by the discharge of the liquor amnii about seven o'clock on Monday evening, and the 
pains followed soon after. They continued through the night and a greater part of the next day — 
sharp, soft, but very ineffectual. Toward the evening Sir Richard Croft began to suspect that 
labor might not terminate without artificial assistance, and a message w ? as despatched for me. 
I arrived at two on Wednesday morning. The labor was now advancing more favorably, and 
both Dr. Baillie and myself concurred in the opinion that it would not be advisable to inform her 
Royal Highness of my'arrival. From this time to the end of her labor the progress was uniform, 
though very slow, the patient in good spirits, the pulse calm, and there never was room to enter- 
tain a question about the use of instruments. About six in the afternoon the discharge became 
of a green color, which led to a suspicion that the child might be dead ; still the giving assistance 
was quite out of the question, as the pains now became more effectual, and the labor proceeded 
regularly, though slowly. The child was born without artificial assistance at nine o'clock in the 
evening! Attempts were made for a good while to reanimate it by inflating the lungs, friction, 
hot baths, etc., but without effect ; the heart could not be made to beat even once. Soon after 
delivery. Sir Richard Croft discovered that the uterus was contracted in the middle in the hour- 
glass form, and as some hemorrhage commenced it was agreed that the placenta should be 
brought away by introducing the hand. This was done about half an hour after the delivery of 
the child, with more ease and less blood than usual. Her Royal Highness continued well" for 
about two hours ; she then complained of being sick at stomach, and of noise in the ears, began 
to be talkative, and her pulse became frequent ; but I understand she was very quiet after this, 
and her pulse calm. About half-past twelve o'clock she complained of severe pain in the chest, 
became extremely restless, with rapid, weak, and irregular pulse. At this time I saw ber for the 
first time. It has been said that we had all gone to bed, but that is not a fact ; Croft did not leave 
her room, Baillie retired about eleven, and I went to my bedchamber and laid down in my clothes 
at twelve. By dissection, some bloody fluid (two ounces) was found in the pericardium, supposed 
to be thrown out in articulo mortis. The brain and other organs all sound, except the right 
ovarium, which was distended into a cvst the size of a hen's egg. The hour-glass contraction of 
the uterus still visible, and a considerable quantity of blood in the cavity of the uterus— but those 
present dispute about the quantity, so much as from twelve ounces to "a pound and a half— her 
uterus extending as high as her navel. The cause of her Royal Highness's death is certainly 
somewhat obscure ; the symptoms were such as attend death irom hemorrhage, but the loss of 
blood did not seem to be sufficient to account for a fatal issue. It is possible that the effusion 
into the pericardium took place earlier than was supposed, and it does not seem to be quite cer- 
tain that this might not be the cause. That I did not see her Royal Highness more early was awk- 
ward, and it would have been better that I had been introduced before the labor was expected ; 
and it should have been understood that when labor came on I should be sent to without waiting 
to know whether a consultation was necessary or not. I thought so at the time, but I could not 
propose such an arrangement to Croft. But this is entirely entre nous. I am glad to hear that 
your son is well, and with all my family, wish to be remembered to him. We were happy to 
hear that he was agreeably married. 

"I remain, my dear Doctor, 

"Ever yours most truly. 

" John Sims, M.D. 

" This letter is confidential, as perhaps I might be blamed for writing any particulars without 
the permission of Prince Leopold." 

What are the facts here shown? Here w r as a delicate young woman, prepared for the trial before 
her, as Baron Stockmar tells us, by " lowering the organic strength of the mother by bleeding, 
aperients, and low diet," who was allowed to go on in lingering feeble labor for no less than fifty 
hours after the escape of the liquor amnii ! Such was the groundless dread of instrumental inter- 
ference then prevalent that, although the case dragged on its weary length with feeble, ineffectual 
pains, everv now and then increasing in intensity and then falling off again, it is stated " there 



PROLONGED AND PRECIPITATE LABORS. 365 

Precipitate Labor Less Common than Lingering". — Undue 
rapidity of labor is certainly more uncommon than its converse, but 
still it is by do means of unfrequenl occurrence. Most obstetric 
works contain a formidable catalogue of evils that may attend i(, such 
as rupture of the cervix, or even of the uterus itself, from violence of the 
uterine action ; laceration of the perineum from the presenting part 
being driven through before dilatation has occurred; fainting from 
the sudden emptying of the uterus ; hemorrhage from the same cause. 
With regard to the child it is held that the pressure to which it is 
subjected, and sudden expulsion while the mother is in the erect posi- 
tion, may prove injurious. AVithout denying that these results may 
possibly occur now and again, in the majority of cases over-rapid 
labor is not attended with any evil effects. 

[As an instance of rapid delivery, I report the following case : In 
September, 1848, a Ill-para of twenty-seven, in Philadelphia, was 
awakened in the night by a violent uterine pain, followed at once by 
a sensation of approaching delivery. Her husband, a noted accoucheur, 
was only up in time to receive the foetus, which came by the same pain 
that awakened his wife. A second foetus (both females) soon followed, 
and the whole labor, in all its stages, occupied but forty-five minutes. 
In two prior and two subsequent labors there was no marked haste in 
uterine action. The mother, who is living at seventy-two, has never 
been a strong woman. — Ed.] 

Precipitate labor may generally be traced to one of two conditions, 
or to a combination of both ; excessive force and rapidity of the pains, 
or unusual laxity and Avant of resistance of the soft parts. The pre- 
cise causes inducing these it is difficult to estimate. In some cases the 
former may depend on an undue amount of nervous excitability, and 
the latter on the constitutional state of the patient tending to relaxa- 
tion of the tissues. 

Whatever the cause, the extreme rapidity of labor is occasionally 
remarkable, and one strong pain may be sufficient to effect the expul- 

never was room to entertain a question about the use of instruments " ; and even " when the dis- 
charge became of a green color, .... still the giving assistance was quite out of the question " ! 
Can any reasonable man doubt that if the forceps had been employed hours and hours be fore- 
say on Tuesday, when the pains fell off— the result would probably have been very different, and 
that the life of the child, destroyed by the enormously prolonged second stage, would have been 
saved? It must be remembered that early on Tuesday morning delivery was expected, so that 
the head must then have been low in the pelvis {vide Stockmar's Memoirs, vol. i. p. 63). It would 
be difficult to find a case which more forcibly illustrates the danger of delay in the second stage 
of labor. Then what follows? The uterus, exhausted by the lengthy efforts it should have been 
spared, fails to contract effectually ; nor do we hear of any attempts to produce contraction by 
pressure. The relaxed organ becomes full of clots, extending up to the umbilicus, and all the 
most characteristic symptoms ol concealed post-partum hemorrhage develop themselves. She 
complained "of being sick at stomach, and of noise in her ears, began to be talkative, and her 
pulse became frequent." Before long other symptoms came on, graphically described by Baron 
Stockmar, and which seem to point to the formation of a clot in the heart and pulmonaVy arte- 
ries—a most likely occurrence after such a history. " Baillie sent me word that he wished me to 
see the Princess. I hesitated, but at last went with him. She was suffering from spasms of the 
chest and difficulty of breathing, in great pain, and very restless, and threw herself continually 
from one side of the bed to the other, speaking now to Baillie, now to Croft. Baillie said to her, 
' Here comes an old friend of yours.' She held out her left hand to me, hastily, and pressed mine 
warmly twice. I felt her pulse ; it was going very fast— the beats now strong, now feeble, now 
intermittent." 

Here was evidently something different from the exhaustion of hemorrhage ; and no one who 
has witnessed a case" of pulmonary obstruction can fail to recognize in this account an accurate 
delineation of its dreadful symptoms. Surely this lamentable story can only lead to the conclu- 
sion that the unhappy and gifted Princess fell a victim to the dread of that bugbear, " meddle- 
some midwifery," which has so long retarded the progress of obstetrics. 

I am, etc., W. S. Playfair. 

Curzon Street, Mayfair, W., November 29, 1872. 



366 LABOK. 

sion of the child with little or no preliminary warning. I have known 
a child to be expelled into the pan of a water-closet, the only previous 
indication of commencing labor being a slight griping pain, which led 
the mother to fancy that an action of the bowels was about to take 
place. More often there is what may be described as a storm of uterine 
contractions, one pain following the other with great intensity, until 
the foetus is expelled. The natural effect of this is to produce a great 
amount of alarm or nervous excitement, which of itself forms one of 
the worst results of this class of labor. It is under such circumstances 
that temporary mania occurs, produced by the intensity of the suffering, 
under which the patient may commit acts, her responsibility for which 
may fairly be open to question. 

Little Treatment Possible. — Little can be done in treating undue 
rapidity of labor. We can, to some extent, modify the intensity of the 
pains by urging the patient to refrain from voluntary efforts, and to 
open the glottis by crying out, so that the chest may no longer be a 
fixed point for muscular action. Opiates have been advised to control 
uterine action, but it is needless to point out that, in most cases, there 
is no time for them to take effect. Chloroform will often be found 
most valuable, from the rapidity with which it can be exhibited ; and 
its power of diminishing uterine action, which forms one of its chief 
drawbacks in ordinary practice, will here prove of much service. 



CHAPTEE X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE 
SOFT PARTS. 

Rigidity of the Cervix a Frequent Cause of Protracted Labor. 
— One of the most frequent causes of delay in the first stage of labor 
is rigidity of the cervix uteri, which may depend on a variety of con- 
ditions. It is often produced by premature escape of the liquor amnii, 
in consequence of which the fluid wedge, which is Nature's means cf 
dilating the os, is destroyed, and the hard presenting part is conse- 
quently brought to bear directly upon the tissues of the cervix, which 
are thus unduly irritated, and thrown into a state of spasmodic con- 
traction. At other times it may be due to constitutional peculiarities, 
among which there is none so common as a highly nervous and emo- 
tional temperament, which renders the patient peculiarly sensitive to 
her sufferings, and interferes with the harmonious action of the uterine 
fibres. The pains, in such cases, cause intense agony, are short and 
cramp-like in character, but have little or no effect in producing dila- 
tation ; the os often remaining for many hours without any appreciable 
alteration, its edges being thin and tightly stretched over the head. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 367 

Less often, and this is generally met with in stout, plethoric women, 
the edges of the OS arc thick and to Ugh. 

The effects of prolongation of labor from this cause will vary much 
under different circumstances, [f the liquor amnii be prematurely 
evacuated, the presenting pari presses directly upon the cervix, and 
the case is then practically the same as it' the labor was in the second 
Stage. Hence grave symptoms may soon develop themselves, and 
early interference may be imperatively demanded. If the membranes 
be unruptured, delay will be of comparatively little moment, and con- 
siderable time may elapse without serious detriment to either the 
mother or child. 

The treatment will naturally vary much with the eause and the 
state of the patient. In the majority of cases, especially if the mem- 
branes be intact, patience and time are sufficient to overcome the ob- 
stacle ; but it is often in the power of the accoucheur materially to aid 
dilatation by appropriate management. Sometimes Nature overcomes 
the obstruction by lacerating the opposing structures ; and cases are on 
record in which even a complete ring of the cervix has been torn off 
and come away before the head. 

Manv remedies have been recommended for facilitating; dilatation, 
some of which no doubt act beneficially. Among those most fre- 
quently resorted to was venesection, and with it was generally asso- 
ciated the administration of nauseating doses of tartar emetic. Both 
these acted by producing temporary depression, under which the 
resistance of the soft parts was lessened. They probably answer best 
in cases in which there was a rigid and tough cervix ; and they might 
prove serviceable, even yet, in stout, plethoric women of robust frame. 
Practically they are now seldom, if ever, employed, and other and less 
debilitating remedies are preferred. The agent, jpai' excellence, most 
serviceable is chloral, which is of special value in the more common 
cases in which rigidity is associated with spasmodic contraction of the 
muscular fibres of the cervix. Two or three doses of fifteen grains, 
repeated at intervals of twenty minutes, are often of almost magical 
efficacy, the pains becoming steady and regular, and the os gradually 
relaxing sufficiently to allow the passage of the head. Should the 
chloral be rejected by the stomach, it may be satisfactorily adminis- 
tered per rectum. Chloroform acts much in the same way, but on the 
whole less satisfactorily, its effects being often too great ; while the 
peculiar value of chloral is its influence in promoting relaxation of the 
tissues, without interfering with the strength of the pains. 

Various local means of treatment may be also advantageously used. 
One is the warm bath, which is much used in France. It is of un- 
questionable valne where there is mere rigidity, and may be used either 
as an entire bath, or as a hip-bath, in which the patient sits from 
twenty minutes to half an hour. The objection is the fuss and excite- 
ment it causes, and, for this reason, it is an expedient seldom resorted 
to in this country. A similar effect is produced, and much more easily, 
by a douche of tepid water upon the cervix. This can be very easily 
administered, the pipe of a Higginson's syringe being guided up to the 
cervix by the index finger of the right hand, and a stream of water 



368 LABOR. 

projected against it for live or ten minutes. Smearing the os with 
extract ol belladonna is advised by Continental authorities, but its 
effects are more than doubtful. Horton 1 advocates the injection into 
the tissue of the cervix of ^ lT of a grain of atropine by means of a hypo- 
dermatic syringe, and speaks very favorably 01 the practice. 

Artificial Dilatation. — Artificial dilatation of the cervix by the 
finger has often been recommended, and has been the subject of much 
discussion, especially in the Edinburgh school, where it was formerly 
commonly employed. It is capable of being very useful, but it may 
also do much injury when roughly and injudiciously used. The class 

: ises in which it is most serviceable are those in which the liquor 
amnii has been long evacuated, and in which the head, covered by the 
tightly stretched cervix, has descended low into the pelvic cavity. 
Under these circumstances, if the finger be passed gently within the os 
during a pain, and its margin pressed upward and over the head, as it 
were, while the contraction lasts, the progress of the case may be mate- 
rially facilitated. This manoeuvre is somewhat similar to that which 
has been already spoken of. when the anterior lip of the cervix is 
caught between the head and the pubic bone, and. if properly per- 
formed, I believe it to be quite safe, and often of great value. It is 
not, however, well adapted for those ases iu which the membranes 
are still intact, or in which the os remains undilated when the head is 
still high in the pelvis. TTlien there is much delay under these con- 
ditions, and interference : - >me kind seems called for. the dilatation 
may be much assisted by the use of caoutchouc dilators, described in 
the chapter on the induction of premature labor, which imitate Nature's 
method of opening up the os. and also act as a direct stimulant to 
uterine : action. But it should be remembered that it is precise 
in such cases that delay is least prejudicial. If. however, the os be 
excessively long in opening, its dilatation may be safely and eriiciently 
by passing within it. and distending with water, one of the 
sniallest-sized bags : and. after this has been in position from ten to 
twenty minutes, it may be ed. and a larger -me substituted. 

Rigidity depending- upon Organic Causes. — Every now and 
again we meet with cases in which the obstacle depends upon organic 
changes in the cervix, the most common of which are cicatricial hard- 
ening from former lacerations ; hypertrophic elongation of the cervix 
from disease antecedent to pregnane}- : or even agglutination and 

. sui : the os uteri. Cicatrices ai generally the result of lacerations 
during former labors. They implicate a portion only of the cervix, 
which they render hard, rigid, and undilatable. while the remainder 
has its natural softness. They can readily be made out by the exam- 
ining linger. A somewhat similar, but much more formidable, obstruc- 
tion is occasionally met with in cases : old-standing hypertrophic 

•~ ligation of the cervix, which is generally associated with prolapse. 
In most cases of this kind the cervix becomes softened daring 
nancy, so that dilatation occurs without any unusual difficulty. But 
this does not always happen. A good example is related by ^Ir. 

1 Amer. Joutil of ObsteL, 1878, voL xL p. 482. 



OBSTRUCTION FROM CONDITION OF SOFT FARTS. 369 

Roper, id the seventh volume of the Obstetrical Transactions (p. 233), 

in which such a cervix formed an almost insuperable obstacle to the 
passage of the child. 

Carcinoma of the cervix uteri, which produces extensive thickening 
and induration of its tissues, and even advanced malignant disease of 

the uterus, is no bar to conception. The relations of malignant disease 
to pregnancy and parturition have recently been well studied by Dr. 

Herman. 1 Me concludes that cancer renders the patient inapt to con- 
ceive, hut that when pregnancy doe- occur there is a tendency to the 
intra-uterine death and premature expulsion of the foetus, and the 
growth of the cancer is accelerated. When delivery is accomplished 
naturally there is generally expansion of the cervix by Assuring of its 
tissue, but the harder forms of cancer may form an insuperable obstacle 
to delivery. 

Agglutination of the margins of the os uteri is occasionally met 
with,' and must, of course, have occurred after conception. It is 
generallv the result of some inflammatorv affection of the cervix during 
the early months of gestation ; aud I have known it recur in the same 
woman in two successive pregnancies. Usually it is not associated 
-with any hardness or rigidity, but the entire cervix is stretched over 
the presenting part, and forms a smooth covering, in which the os may 
only exist as a small dimple, and may be very difficult to detect at all. 
Occlusion of the os uteri from inflammatory change sometimes so 
alters the cervix that no sign of the original opening can be dis- 
covered ; and in two such instances the Cesarean operation has been 
performed in the United States, by which the women were saved. 2 

Their Treatment. — Any of these mechanical causes of rigidity may 
at first be treated in the same way as the more simple cases ; and with 
patience, the use of chloral and chloroform, and of the fluid dilators, 
sufficient expansion to permit the passage of the head will often take 
place. But if these methods produce no effect, and symptoms of con- 
stitutional irritation are beginning to develop themselves, other and 
more radical means of overcoming the obstruction may be required. 

Under such circumstances incision of the cervix may be not only 
justifiable but essential, and it frequently answers extremely well. On 
the Continent it is resorted to much more frequently and earlier than 
in this country, and with the most beneficial results. The operation 
offers no difficulties. The simplest way of performing it is to guard 
the greater portion of the blade of a straight blunt-pointed bistoury by 
wrapping lint or adhesive plaster around it, leaving about half an inch 
of cutting edge toward its point. This is guided to the cervix, on the 
under surface of the index finger, and three or four notches are cut in 
the circumference of the os to about the depth of a quarter of an inch. 
Very generally, especially when the obstruction is only due to old 
cicatrices, the pains will now speedily effect complete expansion, which 
may be very advantageously aided by applying the hydrostatic dilators. 
When the obstruction is due to carcinomatous infiltration or inflam- 
matory thickening, the ease is much more complicated, and will pain- 

1 Obst. Trans, for 1^7<\ vol. xx. p. 191. 

2 Harris's note to second American edition. 

L>4 



370 LABOR. 

fully tax the resources of the accoucheur. If it is possible, the disease 
should be removed as much as cau be safely doue duriug pregnancy, 
which should also be brought to an end before the full period. During 
labor, incisions should form a preliminary to any subsequent proceed- 
ings that may be necessary, as they are, at the worst, not likely to 
iucrease in the least the risk the patient has to run, and they may 
possibly avert more serious operations. In the case of malignant 
disease the risk of serious hemorrhage, from the great vascularity of 
the tissues, must not be forgotten, and, if necessary, means must be 
taken to check this by local styptics, such as perchloride of iron. If 
incision fail, and the state of the patient demands speedy delivery, the 
forceps may be applied, and Herman thinks they are, as a rule, better 
than turning. He also maintains that there is little difference in the 
risk to the mothers between craniotomy and the Cesarean section, and 
that the possibility of saving the child in cases in which incisions have 
failed should induce us to prefer the latter. 

[The experience of our country is decidedly in favor of the improved 
Cesarean operation in cases of cancer of the cervix, and of making the 
section before the pains of labor have commenced, or as soon as pos- 
sible thereafter. There is no reason why such cases should not be 
saved, as the uterine wound heals readily, to which I can bear witness, 
having seen two recoveries under Prof. Goodell. We believe this 
method of delivery to be preferable to the old hysterotomy, or inci- 
sion of the cervix, and to craniotomy, as the passage of the foetus 
through the diseased os uteri is attended with considerable risk to the 
mother. Several women and children have been saved under coelio- 
hysterotomy in our country. — Ed.] 

Application of the Forceps within the Cervix. — Before per- 
forming craniotomy, when the os is sufficiently open, a cautious appli- 
cation of the forceps is quite justifiable. Steady and careful downward 
traction, combined with digital expansion, has often enabled a head to 
pass with safety through an os that has resisted all other means of 
dilatation, and the destruction of the child has thus been avoided. 
If, indeed, the os appear to be dilatable, this procedure may advan- 
tageously be adopted before incision, and, as a matter of fact, it is 
commonly practised in the Rotunda Hospital. An operation involv- 
ing, beyond doubt, of itself some risk, and requiring considerable 
operative dexterity, would naturally not be lightly and inconsiderately 
undertaken. But when it is remembered that the alternative is the 
destruction of the child, the risk of exhaustion, and at least as great 
mechanical injury to the mother, its difficulty need not stand in the 
way of its adoption. 

Treatment when Occlusion of the Os exists. — When the os is 
apparently obliterated, incision is the only resource. Before resorting 
to it the patient should be placed under chloroform, and the entire 
lower segment of the uterus carefully explored. Possibly the aperture 
may be found high up, and out of reach of an ordinary examination, 
or we may detect a depression corresponding to its site. A small 
crucial incision may then be made at the site of the os, if this can be 
ascertained ; if not, at the most prominent portion of the cervix. Very 



OBSTRUCTION" FROM CONDITION OF SOFT PARTS. 371 

generally the pains will then suffice to complete expansion, which may 
be further aided by the fluid dilators. 

Ante-partum Hour-g-lass Contraction. — Dr. Hosmer 1 has drawn 
attention to a hitherto undescribed species of dystocia, which he terms 
"ante-partum hour-glass contraction, and which lie believes to depend 
on constriction of the uterine fibres at the site of the internal OS uteri. 
Dr. Bhmdell refers to it in his work on obstetrics (1840) under the 
title of "Circular Contraction of the Middle of the Womb." Harris 2 
doubts its limitation to the internal os uteri, and terms it "tetanoid 
falciform constriction of the uterus.'* Whatever its site, in the cases 
recorded difficulties of the most formidable kind arose from this cause. 
The pelves were normal and the presentations natural, yet out of seven 
labors four ended fatally, two before delivery. The constriction seems 
to have grasped the foetus with such force as to have rendered extraction, 
either by the forceps or turning, impossible. I have no personal ex- 
perience of this complication, which must fortunately be very rare. 
The introduction of the hand, the patient being deeply anaesthetized, 
would probably render diagnosis easy. The treatment must depend 
on the force and amount of constriction. If the coustrictiou does not 
relax under chloroform, chloral, or the injection of atropine into the 
site of coustrictiou, as recommended by Horton in rigidity of the 
cervix, turning would probably be our best resource. Should this fail, 
the Cesarean section may be required to effect delivery, as happened in 
a case recorded by Dr. T. A. Foster, of Portland, Maine. Coelio- 
elvtrotomy is obviously unsuitable for such cases. 

Bands and Cicatrices in the Vagina. — Extreme rigidity of the 
vagina, or bands and cicatrices in or across its walls, the result of con- 
genital malformation, of injuries in former labors, or of antecedent 
disease, occasionally obstruct the second stage. There is seldom any 
really formidable difficulty from this cause, since the obstruction almost 
always yields to the pressure of the presenting part. If there be any 
considerable extent of cicatrices iu the vagina, artificial assistance may 
be required. If Ave should be aware of their existence during preg- 
nancy, and find them to be sufficiently dense and extensive to be likely 
to interfere with delivery, an endeavor may be made to dilate them 
gradually by hydrostatic bags or bougies. If they be not detected 
until labor is in progress, we must be guided iu our procedure by the 
pressure to which they are subjected. It may then be necessary to 
divide them with a knife, and to hasten the passage of the head by the 
forceps, so as to prevent contusion as much as possible. It is obvi- 
ously impossible to lay down any positive rules for such rare contin- 
gencies, the treatment suitable for which must necessarily vary much 
with the individual peculiarities of the case. 

Extreme Rigidity of the Perineum. — Extreme rigidity of the 
perineum is often dependent upon cicatricial hardening from injury in 
previous labors. This may greatly interfere with its dilatation ; and 
if laceration seems inevitable, we may be quite justified in attempting 

1 Boston Med. and Surg. Journ., 1878, March and May. 

2 Harris's note to second American edition. 



372 LABOR. 

to avert it by incision of the margins of the perineum, on the principle 
of a clean cut being always preferable to a jagged tear. 

Labor complicated with Tumor. — Occasionally we meet with very 
formidable obstacles from tumors connected with the maternal struc- 
tures. These are most commonly either fibroid or ovarian, although 
others may be met with, such as malignant growths from the pelvic 
bones, exostoses, etc. 

Considering the frequency with which women suffer from fibroid 
tumors of the uterus, it is perhaps somewhat remarkable that these do 
not more often complicate delivery. Probably women so affected are 
not apt to conceive. Occasionally, however, cases of this kind cause 
much anxiety. Of course, those cases are most grave in which tumors 
are so situated as to encroach upon the cavity of the pelvis, and me- 
chanically obstruct the passage of the child. Even those in which this 
does not occur are by no means free from danger, for interstitial and 
sub-peritoneal fibroids, situated in the upper parts of the uterus, and 
leaving the pelvic cavity quite unimplicated, may interfere with the 
action of the uterine fibres, prevent subsequent contraction, cause pro- 
fuse post-partum hemorrhage, or even predispose to rupture of the 
uterine tissues. Hence, every case in which the existence of uterine 
fibroids has been ascertained must be anxiously watched. The risk of 
hemorrhage is perhaps the greatest ; for, if the tumors be at all large, 
efficient contraction of the uterus after the birth of the child must be 
more or less interfered with. Fortunately it is not so common as might 
almost be expected. Out of five cases recorded in the Obstetrical Trans- 
actions, two of which were in my own practice, no hemorrhage oc- 
curred ; nor does it seem to have happened in any of the twenty-six 
cases collected by Magclelaine in his thesis on the subject. I recently 
saw an interesting example of this in a patient whose case was looked 
forward to with much anxiety, in consequence of the existence of 
several enormous fibroid masses projecting from the fundus and 
anterior surface of the body of the uterus, and whose labor Avas, never- 
theless, typically normal in every way. Should hemorrhage occur 
after delivery, the injection of styptic solutions would probably be 
peculiarly valuable, since the ordinary means of promoting contraction 
are likely to fail. 

It is when the fibroid growths implicate the lower uterine zone and 
the cervical region that the greatest difficulties are likely to be met 
with. The practice then to be adopted must be regulated to a great 
extent by the nature of each individual case. If it be possible to push 
the tumor above the pelvic brim, out of the way of the presenting part, 
that, no doubt, is the best course to pursue, as not only clearing the 
passage in the most effectual way, but removing the tumor from the 
bruising to which it would otherwise be subjected when pressed between 
the head and the pelvic walls, which seems to be one of the greatest 
dangers of this complication. This manoeuvre is sometimes possible 
in what seem to be the most unpromising circumstances. An interest- 
ing example is narrated by Sir Spencer Wells, 1 who, called to perform 

i Obst. Trans., 1867, vol. ix. p. 73. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 373 

the Csesarean section, succeeded, although not without much difficulty, 
in pushing the obstructing mass above the brim, the child subsequently 
passing with ease. I have myself elsewhere recorded two similar 

cases 1 in which I \\as enabled to deliver the patient by pushing up the 
obstructing tumor, in both of which the Csesarean section would have 
been inevitable had the attempt at reposition failed. Therefore, before 

resorting to more serious operative procedures, a determined effort at 
pushing the tumor out of the way should be made, the patient being 
deeply chloroformed, and, if necessary, upward pressure being made 
by the closed fist passed into the vagina. 2 

Failing this, the possibility of enucleating the tumor, or if that be 
not possible, of removing it piecemeal with the ecraseur, should be 
considered. On account of the loose attachments of these growths, 
and the facility with which they can be removed in this way in the 
non-pregnant state, the expedient seems certainly well worthy a trial, 
if their site and. attachments render it at all feasible. Interesting 
examples of the successful performance of this operation are recorded 
by Dan van, Braxton Hicks, Lomer, and Munde. Should it be found 
impracticable, the case must be managed in reference to the amount of 
obstruction ; and the forceps, craniotomy, or even one of the varieties 
of abdominal section may be necessary. Out of forty-five old Csesarean 
operations collected by Harris and Sanger, thirty-six proved fatal. 
Probably Porro's operation would give the patient a better chance, and 
of this several successful cases are recorded. ( Vide p. 233.) 

[The Cesarean operation, with removal of the uterus, is preferable 
to the conservative method, and less apt to prove fatal ; besides having 
the additional advantage of removing the diseased growth. In nine 
Porro-Csesarean operations in fibroid cases in the United States, five 
ended in recovery, and five children were saved. The last four cases 
in order recovered, with two children saved. — Ed.] 

The proportion of breech presentations in cases of fibro-myoma 
complicating delivery is much larger than usual ; out of one hundred 
cases Lefour 3 observed thirty-two breech presentations, and Chabazain 
gives the proportion as 26 per cent. This is probably due to the 
altered shape of the uterine cavity caused by the tumor. 

Tumors of the Ovaries. — The next most common class of obstruct- 
ing tumors are those of the ovary (Fig. 129), and it is apparently not 
the largest of these which are most apt to descend into the pelvic 
cavity. When the tumor is of any considerable size, its bulk is such 
that it cannot be contained in the true pelvis, and it rises into the 
abdominal cavity with the uterus. Hence, the existence of the tumor 
that offers the most formidable obstacle to delivery is rarely suspected 
before labor sets in. 

In order to estimate the results of the various methods of treatment, 
I have tabulated fifty-seven cases. 4 In thirteen, labor was terminated 
by the natural powers alone ; but of these, six mothers, or nearly one- 

i Ibid, for 1877, vol. xix. p. 101. 

2 This procedure is objected to in Dr. John Phillips's paper already quoted, but it seems to me on 
insufficient grounds 

3 E. Blanc : Annal. de Gvn., torn. xxxv. p. 197. 
* Obst. Trans., 1867, vol. ix. p. 69. 



374 LABOR. 

half, died. In favorable contrast with these, Ave have the cases in 
which the size of the tumor was diminished by puncture. These are 
nine in number, in all of which the mother recovered ; five out of the 
six children being saved. The reason of the great mortality in the 
former cases is apparently the bruising to which the tumor, even when 
small enough to allow the child to be squeezed past it, is necessarily 
subjected. This is extremely apt to set up a fatal form of diffuse in- 
flammation, the risk of which was long ago pointed out by Ashwell, 1 
who draws a comparison between cases in which such tumors have 
been subjected to contusion and cases of strangulated hernia ; and the 
cause of death in both is doubtless very similar. This danger is 

Fig. 129. 




Labor complicated by ovarian tumor. 

avoided when the tumor is punctured, so as to become flattened between 
the head and the pelvic walls. On this account I think it should be 
laid down as a rule that puncture should be performed in all cases of 
ovarian tumor engaged in front of the presenting part, even when it is 
of so small a size as not to preclude the possibility of delivery by the 
natural powers. 

In five of the fifty-seven cases it was found possible to return the 
tumor above the pelvic brim, and in these also the termination was 
very favorable, all the mothers recovering. Should puncture not 
succeed, and it may fail on account of the gelatinous aud semi-solid 
nature of the contents of the cyst, it may be possible to dispose of the 
tumor in this way, even when it seems to be firmly wedged down in 
front of the presenting part, and to be hopelessly fixed in its unfavor- 
able position. 

Failing either of these resources, it may be necessary to resort to 
craniotomy, provided the size of the tumor precludes the possibility of 
delivery by forceps. 

1 Guy's Hospital Reports, 1836, No. 2, p. 300. 



OBSTRUCTION FROV ITIOX OF SOFT PART- 

The question oi varian tumor which 

Ivic canal is one of some interes 

- ient numb; f cases :•> throw much light on it I 

an: disposed to think that b _ nerally goes on favorably. 1 

delay there is - »n the ineffii the aco ae 

inuscl - _ _ in parturition, on account of the extreme distention 

Thei a .... ted with the maternal struc- 

b which may impede delivery, but which omparatively rare 

oecurren 

Vaginal Cystocele. — Amongst them i- vaginal cyst rating 

of a prolapse of the distended bladder in front of the presentation, 
where it forms a tense fluctuating pouch which has been mistak 
a hydrocephalic head, or for t:. _ :' membranes. This complica- 
tion i- only likely to arise when the bladder has been alio' 'X»me 
unduly distended from want of attention to the voiding of urine during 
labor. The di _ - 9 should not offer any difficulty, for the linger 
will be able to pass behind, but not in front of. the swelling, and 
reach the presenting part : while the pain and tenesmus will further 
put the practitioner on his guard. The treatment consists in emptying 
the bladder ; but there may be s«:»me difficulty in passing the catheter, 
sequence of the urethra being dn __■.■ 1 out of its natural direction. 
A long elastic male catheter will almost always pass, if used with eare 
Should it be found impossible to draw off the water 
— and this iss I - ti s hap] ned — the tense pouch might 
be punctured without danger by the line needle oi an aspirator trocar, 
and its contents withdrawn. AVhen once~tb vis s is emptied, : 
easily be pus l senting part in the intervals between 
•ins. 

Vesical Calculus. — In some few ises .iiticulties have arisen from 
the existence of a vesical calculus. Should this be pushed down in 
front of the head, it can readily be understood that the maternal 
structures would run the risk of being seriously bruised and injured. 
Should we make out th - calculus — and. if the presence 

of one be susr I gnosis sily be ms ans of s 

sound — an endeavor should be made to push it above the brim of the 
pelvis. If that be found to be impossible, no resource is left but its 
al. either by crushing, or by rapid dilatation of the urethra. 
followed by extraction. Should we be aware of the existence : 
calculus durii:_ ... r , its moval should certainly be undertaken 
before labor sets in. 

Hernial protrusion in Douglas's space may sometimes give ris I 
anxiety, from the pressure and contusion to which it is necessarily 
subjected. An endeavor must be made to replace it. and to moderate 
the straining efforts of the patient : and it may even be advisable to 
apply the foro ps e as t relieve the mass from pi ssu] 3 e on as 

9sible. It is. h of g rarity. Barker, in an in- 

d the subject. 1 records several examples, and states 

1 Amer. Journ. of Obst., 1ST6, voL Ls. p. 177. 



376 LABOR. 

that he has met with no instance in which it has led to a fatal result, 
either to mother or child, although it cannot but be considered a serious 
complication. 

Scybalous masses in the intestines may be so hard and impacted 
as to form an obstruction. The necessity of attending to the state of 
the rectum has already been pointed out. Should it be found impos- 
sible to empty the bowel by large eneruata, the mass must be mechan- 
ically broken down and removed by the scoop. 

[Our Southern readers are aware of the fact that their lowest class 
of women living in the country sometimes eat clay as a remedy for 
heartburn, and occasionally in excessive quantities, during the pregnant 
state. Impacted clay in the lower bowels has on two occasions proved 
such an obstacle to delivery that the Cesarean operation was performed, 
one case occurring in Louisiana and the other in Georgia, in the years 
1866 and 1882 respectively, after labors of sixty hours and three days. 
The first case recovered, the clay being removed by an attack of diar- 
rhoea on the sixth day. The second died of convulsions in twenty 
days after the uterine and abdominal wounds had healed. Under 
chloroform about two and a half pounds of sand and marl were 
removed three days after the operation. — Ed.] 

(Edema of the Vulva. — Excessive oedematous infiltration of the 
vulva may sometimes cause obstruction, and require diminution in size, 
which can easily be effected by numerous small punctures. 

Hsematic effusions into the cellular tissue of the vulva or vagina 
form a grave complication of labor. Such blood-swellings are most 
usually met with in one or both labia, or under the vaginal wall ; in 
the gravest forms, the blood may extend into the tissues for a con- 
siderable distance, as in the case recorded by Cazeanx, where it reached 
upward as far as the umbilicus in front, and as far as the attachment 
of the diaphragm behind. 

The conditions associated with pregnancy, the distention and en- 
gorgement to which the vessels are subjected, the interference with the 
return of the blood by the pressure of the head during labor, and the 
violent efforts of the patient, afford a ready explanation of the reason 
why a vessel may be predisposed to rupture and admit the extravasa- 
tion of blood. 

The accident is fortunately far from a common one, although a 
sufficient number of cases are recorded to make us familiar with its 
symptoms and risks. The dangers attending such effusions would 
seem to be great, if the statistics given by those who have written on 
the subject are to be trusted. Thus, out of one hundred and twenty- 
four cases collected by various French authors, forty-four proved fatal. 
Fordyee Barker points out that, since the nature and appropriate 
treatment of the accident have been more thoroughly understood, the 
mortality has been much lessened ; for out of fifteen cases reported by 
Scanzoni only one died, and out of twenty-two cases he had himself 
seen, two died, and all these three deaths were from puerperal fever, 
and not the direct result of the accident. 1 

1 The Puerperal Diseases, p. 60. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. o7 7 

The blood may be effused into any part of the pelvic cellular tissue, 
or into the labia. The accident most often happens during labor when 

the head is low down in the pelvis, not unfrequently just as it is about 
to escape from the vulva. Hence the extravasation is more often met 
with low down in the vagina, and more frequently in one of the labia 
than in any other situation. I have met with a ease in which 1 had 
every reason to believe that an extravasation of blood had occurred 
within the tissues immediately surrounding the cervix. Jt is natural 
to suppose that a varicose condition of the veins about the vulva 
would predispose to the accident, but in most of the recorded ex- 
amples this is not stated to have been the case. Still, if varicose 
veins exist to any marked degree, some anxiety on this point cannot 
but be felt. 

The thrombus occasionally, though rarely, forms before delivery. 
Most commonly it first forms toward the end of labor, or after the 
birth of the child. In the latter case it is probable that the laceration 
in the vessels occurred before the birth of the child, and that the 
pressure of the presenting part prevented the escape of any quantity 
of blood at the time of laceration. 

The symptoms are not by any means characteristic. Pain of a 
tearing character, occasionally very intense, and extending to the back 
and down the thighs, is very generally associated with the formation 
of the thrombus. If a careful physical examination be made, the 
nature of the case can readily be detected. When the blood escapes 
into the labium, a firm, hard swelling is felt which has even been mis- 
taken for the foetal head. If the effusion implicate the internal parts 
only, the diagnosis may not at first be so evident. But even then a 
little care should prevent any mistake, for the swelling may be felt in 
the vagina, and may even form an obstacle to the passage of the 
child. Cazeaux mentions cases in which it was so extensive as to 
compress the rectum and urethra, and even to prevent the exit of the 
lochia. In some cases the distention of the tissues is so great that 
they lacerate, and then hemorrhage, sometimes so profuse as directly 
to imperil the life of the patient, may occur. The bursting of the 
skin may take place some time subsequent to the formation of the 
thrombus. Constitutional symptoms will be in proportion to the 
amount of blood lost, either by extravasation cr externally, after 
the rupture of the superficial tissues. Occasionally they are consider- 
able, and are the same as those of hemorrhage from any cause. 

The terminations of thrombus are either spontaneous absorption, 
which may occur if the amount of blood extravasated be small ; or 
the tumor may burst, and then there is external hemorrhage ; or it 
may suppurate, the contained coagula being discharged from the cavity 
of the cyst ; or, finally, sloughing of the superficial tissues has occurred. 

The treatment must naturally vary with the size of the thrombus, 
and the time at which it forms. If it be met with during labor, 
unless it be extremely small, it will be very apt to form an obstruction 
to the passage of the child. Under such circumstances it is clearly 
advisable to terminate the labor as soon as possible, so as to remove 
the obstacle to the circulation in the vessels. For this purpose the 



378 LABOR. 

forceps should be applied as soon as the head can be easily reached. 
If the tumor itself obstruct the passage of the head, or if it be of any 
considerable size, it will be necessary to incise it freely at its most 
prominent point and turn out the coagula, controlling the hemorrhage 
at once by filling the cavity with cotton wadding saturated in a solu- 
tion of perchloride of iron, while at the same time digital compression 
with the tips of the fingers is kept up. By this means pressure is 
applied directly to the bleeding-point, and the hemorrhage can be 
controlled without difficulty. This is all the more necessary if spon- 
taneous rupture has taken place, for then the loss of blood is often 
profuse, and it is of the utmost importance to reach the site of the 
hemorrhage as nearly as possible. 

If the thrombus be not so large as to obstruct delivery, or if it be not 
detected until after the birth of the child, the question arises whether 
the case should not be left alone, in the hope that absorption may occur, 
as in most cases of pelvic hematocele. This expectant treatment is 
advised by Cazeaux, and it seems to be the most rational plan we can 
adopt. True, it may take a longer time for the patient to convalesce 
completely than if the coagula were removed at once, and the hemor- 
rhage restrained by pressure on the bleeding-point; but this disad- 
vantage is more than counterbalanced by the absence of risk from 
hemorrhage, and of septicaemia from the suppuration that must 
necessarily follow. Softening and suppuration may in many cases 
occur in a few days, necessitating operation, but the vessels will then 
be probably occluded, and the risk of hemorrhage be much lessened. 
The late Dr. Fordyce Barker, however, held the opposite opinion, 
and thought that the proper plan Mas to open the thrombus early, 
controlling the hemorrhage in the manner already indicated, unless 
the thrombus is situated high in the vaginal canal. 

Whenever the cavity of a thrombus has been opened, either by in- 
cision or by spontaneous softening at some time subsequent to its 
formation, it must not be forgotten that there is considerable risk of 
septic absorption. To avoid this, care must be taken to use antiseptic 
dressings freely, such as iodoform powder or wool, applied directly to 
the part, and frequent vaginal injections of diluted Gondy's fluid. 
Barker laid special stress upon the importance of not removing 
prematurely the coagula formed by the " styptic applications, for fear 
of secondary hemorrhage, but of allowing them to come away 
spontaneously. 

[Polypus. — Large uterine polypi may act as serious obstacles to 
delivery. When sufficiently long in pedicle, a polypus may be ex- 
truded before the head of the foetus. The tumor may also be detached 
in its expulsion, or may be removed by an ecraseur if recognized in 
time ; it may also be pushed up out of the way and secured by bring- 
ing down the child. I once replaced a large polypus that was extruded 
before the head, and the woman carried it two years longer ; by which 
time, being much wasted by the discharge, she made up her mind to 
have it removed, — Ed.] 



DYSTOCIA FKuil FCETUS. 



379 



CHAPTER XI. 

DIFFICULT LABOR DEPENDING OX SOME UNUSUAL 
CONDITION OF THE FOETUS. 

Plural Births. — The subject of multiple pregnancy in general 
having already been fully considered, Ave have now only to discuss its 
practical beariug as regards labor. Fortunately, the existence of 
twins rarely gives rise to any serious difficulty. In the large propor- 
tion of cases the presence of a second foetus is not suspected until the 
birth of the first, when the nature of the case is at once apparent from 
the fact of the uterus remaining as large, or nearly as large, as it was 
before. 

There may possibly be some delay in the birth of the first child, 
inasmuch as the extreme distention of the uterus mav interfere with 



Fig. 130. 




Twin pregnancy, breech and head presenting. 



its thoroughly efficient action ; while, in addition, the uterine joressure 
is not directly conveyed to the ovum as in single births, but in- 
directly through the amniotic sac of the second child (Fig. 130). Such 
delay is especially apt to arise when the first child presents by the 
breech, for, even if the body be expelled spontaneously, difficulty is 
likely to occur with the head, since the uterus does not contract upon 



380 LABOR. 

it as is ordinarily the case. Hence the intervention of the accoacheur 
to save the life of the child, by the extraction of the head, will be 
almost a matter of necessity. 

In the majority of cases, after the birth of the first child, there is a 
temporary lull in the pains, which soon recommence, generally in 
from ten to twenty minutes, and the second child is rapidly expelled ; 
for on account of the full dilatation of the soft parts, there is no 
obstacle to its delivery. Sometimes there is a considerable interval 
before the pains recur, and instances are recorded in which even 
several days elapsed between the births of the two children. 

Treatment. — In most cases the management of twins does not differ 
from that of ordinary labor. As soon as we are certain of the exist- 
ence of a second foetus, we should inform the bystanders, but not 
necessarily the mother, to whom the news might prove an unpleasant 
and even dangerous shock. Then, having taken care to tie the cord 
of the first child for fear of vascular communication between the pla- 
centa?, our duty is to wait for a recurrence of the pains. If these come 
on rapidly, and the presentation of the second foetus be normal, its 
birth is managed in the usual way. 

If there be any unusual delay, Ave have to consider the proper course 
to pursue, and on this the opinions of authorities differ greatly. Some 
advise a delay of several hours, and even more, if pains do not recur 
spontaneously ; while others — Murphy, for example — recommend that 
the second child should be delivered at once. Either extreme of prac- 
tice is probably wrong, and the safest and best course is, doubtless, the 
median one. The second point to bear in mind is, that in multiple 
pregnancy, on account of the extreme distention of the uterus, there is 
a tendency to inertia, and consequently to post-partum hemorrhage ; 
and that, therefore, it is better that the birth of the second child should 
be delayed, even for a considerable time, rather than that the patient 
should run the risk attending an empty and uncontracted uterus. If, 
however, uterine action be present, there is an obvious advantage in 
the delivery of the second child before the dilatation of the passages 
passes off. 

The best plan would seem to be, if, after waiting a quarter of an 
hour, labor-pains do not occur, to try and induce them by uterine fric- 
tion and pressure, and by the administration of a dose of ergot, to 
which, as there can be no obstacle to the rapid birth of the second 
child, there can be now no objection. The membranes of the second 
child should always be ruptured at once, if easily within reach, as one 
of the speediest means of inducing contraction. If no progress be 
made, and speedy delivery be indicated — a necessity which may arise 
either from the exhausted state of the patient, the presence of hemor- 
rhage, extremely feeble pulsations of the foetal heart (showing that the 
life of the second child is endangered), or malpresentation of the 
second foetus — turning is probably the readiest and safest expedient. 
Under such circumstances the operation is performed with great ease, 
since the passages are amply dilated. After bringing down the feet, 
the birth of the body should be slowly effected, with the view of insur- 
ing as complete subsequent contraction as possible. If the head has 



DYSTOCIA FROM FOETUS 



381 



descended in the pelvis, of course turning is impossible, and the forceps 

must be applied. 

Difficulties arising- from Locked Twins. — Occasionally very 
serious difficulties arise from parts of both foetuses presenting simulta- 
neously, and thus impeding the entrance of either child into the pelvis, 
or getting locked together, so as to render delivery impossible without 
artificial aid. Such difficulties are not apt to arise in the more ordi- 
nary cases, in which each child has its own bag of membranes, since 
then the foetuses are kept entirely separate ; but in those in which the 
twins are contained in a common amniotic cavity, or in which both 
sacs have burst simultaneously. They are very puzzling to the obste- 
trician, and it may be far from easy to discover the cause of the 
obstruction. Nor is it possible to lay down any positive rules for their 
management, which must be governed, to a considerable extent, by the 
circumstances of each individual case. 



Fig. 131. 




Shows head-locking, both children presenting head first. (After Baexes.) 

Sometimes both heads present simultaneously at the brim, and then 
neither can enter unless they be unusually small or the pelvis very 
capacious, when both may descend ; or rather the first head may 
descend low into the pelvic cavity, and then the second head enters the 
brim, and gets jammed against the thorax of the first child (Fig. 131). 

Reimann l relates a curious example of this, in which he delivered 
the head first with the forceps, but found the body would not follow, 
and, on examination, a second head was found in the pelvis. He then 
applied the forceps to the second head ; the body of the first child was 
then born, and afterward that of the second. Such a mechanism must 



i Arch. f. Gynak., 1871, Bd. ii. p. 99. 



382 LABOR. 

clearly have been impossible unless the pelvis had been extremely 
large. 

Whenever both heads are felt at the brim, it will generally be found 
possible to get one out of the way by appropriate manipulation, one 
hand being passed into the vagina, the other aiding its action from 
without. Then the forceps may be applied to the other head, so as to 
engage it at once in the pelvic cavity. If both have actually passed 
into the pelvis, as in the case just alluded to, the difficulty will be 
much greater. It will generally be easier to push up the second head 
while the lower is drawn out by the forceps, than to deliver the second, 
leaving the first in situ. 

In other cases a foot or a hand may descend along with the head, 
and even the four feet may present simultaneously. The rule in the 
former case is to push the part descending with the head out of the 
way, and in the latter to disengage one child as soon as possible. 
Great care is necessary, or we might possibly bring down the limbs of 
separate children. 

The most common kind of difficulty is when the first child presents 
by the breech, and is delivered as far as the head, which is then found 
to be locked with the head of the second child, which has descended 
into the pelvic cavity (Fig. 132). 

Here it is clear that the obstruction must be very great, and, unless 
the children are extremely small, insuperable. The first endeavor 
should be to disentangle the heads ; this is sometimes feasible if the 
second be not deeply engaged in the pelvis, and the hand be passed up 
so as to push it out of the way. This will but rarely succeed ; then it 
may be possible to apply the forceps to the second head and drag it 
past the body of the first child, and this is the method recommended 
by Reirnann, who has written an excellent paper on the subject. 1 
Generally the sacrifice of one of the children is essential, and as the 
body of the first child must have been born for some time, it is prob- 
able that the pressure to which it has been subjected will have already 
imperilled, if it has not destroyed, its life, and therefore the plan 
usually recommended is to decapitate. This can be easily done with 
scissors or a wire 6craseur, after which the second child is expelled 
without difficulty, leaving the head of the first in utero to be subse- 
quently dealt with. 

Another mode of managing these cases is to perforate the upper head 
and draw it past the lower with the cephalotribe or craniotomy forceps. 
This plan has the disadvantage of probably sacrificing both children, 
since the other child can hardly survive the pressure and delay, w^hereas 
the former plan gives the second child a fair chance of being born alive. 

Double Monsters. — In connection with the subject of twin labor 
we may consider those rare cases in which the bodies of the foetuses are 
partially fused together. The mechanism and management of delivery 
in cases of double monstrosity have attracted comparatively little atten- 
tion, no doubt because authors have considered them matters of curi- 
osity merely, rather than of practical importance. . 

1 American Journal of Obstetrics, 1877, vol. x. p. 47. 



DYSTOCIA FROM FCETUS 



383 



The frequent occurrence of such monstrosities in our museums, and 
the numerous cases scattered through our periodica] literature, are 
sufficient to show that they are not so very rare as we might be 
inclined to imagine ; and, as they are likely to give rise to formidable 
difficulties in delivery, it cannot be unimportant to have a clear idea 
of the usual course taken by Nature in effecting such births, with a 
view of enabling us to assist in the most satisfactory manner should a 
similar case come under our observation. 

Fig. 132. 




Shows head-locking, first child coming feet first ; impaction of heads from wedging in brim, d. 
Apex of wedge, e. c. Base of wedge, which cannot enter brim. a. b. Line of decapitation to 
decompose wedge, and enable head of second child to pass. (After Babxes.) 



Unfortunately, the authors who have placed on record the birth of 
double monsters have generally occupied themselves more with a 
description of the structural peculiarities of the foetuses than with the 
mechanism of their delivery; so that, although the cases to be met with 
in medical literature are very numerous, comparatively few of them 
are of real value from an obstetric point of view. Still, I have been 



384 LABOR. 

able to collect the details of a considerable number 1 in which the his- 
tory of the labor is more or less accurately described ; and doubtless a 
more extensive research would increase the list. 

Double Monstrosity may be Divided into Pour Classes. — For 
obstetric purposes we may confine our attention to four principal 
varieties of double monstrosity, which are met with far more frequently 
than any others. These are : 

A. Two nearly separate bodies united in front to a varying extent, 
by thorax or abdomen. 

B. Two nearly separate bodies united back to back by the sacrum 
and lower part of the spinal column. [ 2 ] 

C. Dicephalous monsters, the bodies being single below, but the 
heads separate. [ 3 ] 

D. The bodies separate below, but the heads partially united. 
This classification by no means includes all the varieties of monsters 

that we may meet with. It does, however, include all that are likely 
to give rise to much difficulty in delivery ; and all the cases I have 
collected may be placed under one of these divisions. 

The first point that strikes us in looking over the history of these 
deliveries is the frequency with which they have been terminated by 
the natural powers alone, without any assistance on the part of the 
accoucheur. Thus, out of the 31 cases, no less than 20 were delivered 
naturally, and apparently without much trouble. Nothing can better 
show the wonderful resources of Nature in overcoming difficulties of a 
very formidable kind. 

It is pretty generally assumed by authors that the children are 
necessarily premature, and therefore of small size, and that delivery 
bofore the full term is rather the rule than the exception. Duges 
states that the children are often dead, and that putrefaction has taken 
place, which facilitates their expulsion. Both these assumptions seem 
to me to have been made without sufficient authority, and not to be 
borne out by the recorded facts. In only one of the 31 cases is it men- 
tioned that the children were premature ; nor is there any sufficient 
reason that I can see why labor should commence before the full term 
of gestation. 

Class A. — By far the greatest number are included in the first 
class — that in which the bodies are nearly separate, but united by some 
part of the thorax or abdomen. This is the division which includes 
the celebrated Siamese Twins, an account of whose birth, I may ob- 
serve, I have not been able to discover. 4 [It also includes the Orissa 

1 Obst. Trans., 1867, vol. viii. p. 300. 

2 [As in the Carolina Sisters (colored), now living at the age of forty-two; and the Bohemian 
Sisters, Blazek, born January 20, 1878, also still living. Rosalie Blazek came by the head— the 
pelvis and four legs followed the delivery of her thorax— and finally the chest and head of Josepha 
were delivered.— Ed.] 

3 [As in the Tocci Brothers, now living, who were born at Locana, Italy, on October 4. 1877. 
Their analogue, the "Rita-Christina," of Sassari, Island of Sardinia, 1829, lived eight months - 
March 12th to November 23d.— Ed.] 

* The mother of these twins was a Chinese half-breed, short, and with a broad pelvis, and had 
borne several children previously. She stated on several occasions, in conversation with parties 
in Siam, that the twins were born reversed, the feet of one being followed by the head of the other, 
and that they were very small and feeble at birth and for several months afterward. The twins 
confirmed this statement by affirming that they could, when little boys at play on the ground, turn 
themselves end for end upon the ensiform attachment up to the age of ten or twelve, the attach- 
ment being then soft and pliable.— Harris's note to second American edition. 

[These twins were three-quarters Chinese, their father being a Chinaman. Their mother Avas 
sesn by Dr. W. S. W. Ruschenberger, in Bangkok, and described as above.— Ed.] 



DYSTOCIA FROM FCETUS. 385 

Sisters, of India, recently shown in London, nearly four years old. 
Their birth was a very easy one.] Out of the ;>1 eases, 1!) come under 
this beading. The details of the labors are briefly as follows: 1 died 
undelivered ; S were terminated by the natural powers (in three of 
which the feet, and in three the head presented, in two the presentation 
is doubtful); (> were delivered by turning, or by traction on the lower 
extremities ; 4 were delivered instrnnientally. 

The details of the eases in which the feet presented, or in which 
turning was performed, clearly show that footling presentation was 
by far the most favorable, and it is fortunate that the feet often present 
naturally. The inference, of course, is that version should be resorted 
to whenever any other presentation is met with in cases of double 
monstrosity of this type; but, unfortunately, this rule could rarely be 
carried into execution, since we possess no means of diagnosing the 
junction of the foetuses at a sufficiently early stage of labor to admit 
of turning being performed. It is only under exceptionally favorable 
circumstances that this can be done ; as, for example, in a case recorded 
by Molas, in which both heads presented, but neither w r ould enter the 
brim of the pelvis. 

The great difficulty must, of course, be in the delivery of the heads, 
for in all the recorded cases, with one exception, the bodies have passed 
through the pelvis parallel to each other with comparative ease until 
the necks have appeared, and then, as a rule, they could be brought 
no further. It is clear that the remainder of the foetuses could no 
longer pass simultaneously ; and, were direct traction continued, the 
heads would be inextricably fixed above the brim. In accordance 
with the direction of the pelvic axes the posterior head must first 
engage in the inlet ; and, in order to effect this, it will be necessary to 
carry the bodies of the children well over the abdomen of the mother. 
This seems to be a point of primary importance. It would also be 
advisable to see that the bodies are made to pass through the pelvis 
with their backs in the oblique diameter. By this means more space 
is gained than if the backs were placed antero-posteriorly • while, at 
the same time, there is less chance of the heads hitching against the 
promontory of the sacrum and symphysis pubis, which otherwise Avould 
be very apt to occur. 

When the head presents, and the labor is terminated by the natural 
powers, delivery seems to be accomplished in one of two w r ays. 

In the first and more common, the head and shoulders of one child 
are born, its breech and legs being subsequently pushed through the 
pelvis by a process similar to that of spontaneous evolution ; and, 
afterward, the second child probably passes footling without much 
difficulty. 

Barkow relates a case in which both heads were delivered by the 
forceps, the bodies subsequently passing simultaneously. Two similar 
instances are recorded in the third and sixth volumes of the Obstetrical 
Transactions. When delivery takes places in this manner, the head 
of the second child must fit into the cavity formed by the neck of the 
first, and the pelvis must necessarily be sufficiently roomy to admit of 
the expulsion of the head of the second child while its cavity is dimin- 

25 



386 LABOR. 

ished in size by the presence of the neck and snoulders of the first. 
Either of these processes must obviously require exceptionally favor- 
able conditions as regards the size of the child and the pelvis ; and the 
difficulty in the way of delivery must be much greater than when the 
lower extremities present. Therefore, I think the rule should be laid 
down that, when the nature of the case is made out (and for the pur- 
pose of accurate diagnosis a complete examination under anaesthesia 
should be practised), turning should be performed, and the feet brought 
down. 

In the event of its being found impossible to effect delivery after a 
considerable portion of the bodies is born, no resource remains but the 
mutilation of the body of one child, so as to admit of the passage of 
the other. This was found necessary in one case in which the children 
presented by the feet, and were born as far as the thorax, but could 
get no further. The body of the anterior child was removed by a 
circular incision as far as it had been expelled, which allowed the 
remaining portion, consisting of the head and shoulders, to re-enter 
the uterus ; after this the posterior child was easily extracted, and the 
mutilated foetus followed without difficulty. 

Class B. — In class B, in which the children are united back to back, 
[4] cases are recorded, all of which were delivered by the natural 
powers [and alive]. One of these is the case of Judith and Helene, 
the celebrated Hungarian twins, who lived to the age of twenty-one. 
Helene was born as far as the umbilicus, and, after the lapse of three 
hours, her breech and legs descended. Judith w r as expelled imme- 
diately afterward, her feet descending first. [*] Exactly the same 
process occurred in a case described by M. Norman, the children being 
also born alive, and dying on the ninth day. [The fourth case is 
that of the Bohemiau sisters already mentioned. — Ed.] 

It is probable that labor is easier in this class of double monsters 
than in the former, because the children are so joined that there 
is no necessity for the bodies to be parallel to each other during 
birth when the head presents, and after the birth of the head and 
shoulders of the first child, its breech and lower extremities are 
evidently pushed down and expelled by a process of spontaneous evo- 
lution. If the feet originally presented, the mechanism of delivery 
and the rules to be followed would be the same as in class A ; but the 
difficulty would probably be greater, since the juncture is not so flexible, 
and a more complete parallelism of the bodies would be necessary 
during extraction. 

Class C. — In class C, that of the dicephalous monters, I have found 
the description of the birth of eight cases, three of which were termi- 
nated by the natural powers. In two of these, the process of evolution 
was the main agent in delivery ; one head being born and becoming 
fixed under the arch of the pubes, the body being subsequently pushed 
past it, and the second head following without difficulty. This process 

[! The celebrated Carolina twins, born July 11, 1851, and still living, were brought into the world 
by the same method, but the mother, having a large pelvis, had " a brief and easy " delivery. The 
larger of the two girls also came first, as in the Tzoni case of 1701. These twins are twice as old as 
the Hungarian sisters were at death.— Ed.] 



DYSTOCIA FROM FCETUS. 387 

failing, the proper course is to decapitate the first-born head, and then 
bring down the feet of the child, when delivery can be accomplished 
with ease. This was the course adopted in two out of the eight cases; 

and it may be done with the less hesitation since, from their structural 
peculiarities, it is extremely improbable that monsters of this kind 
should survive. In the third ease, terminated naturally, the heads 
were said to have been born simultaneously, but it seems probable that 
the one head lay in the hollow formed by the neck of the other, and so 
rapidly followed it. If the feet presented, the ease might be managed 
in the same manner as in class A. 

[Of class C, I have a record of twelve cases, eight united boys, and 
four girls, born from 1316 to 1877, inclusive. Five of the male twins, 
and two of the female, were born alive. The male twins lived re- 
spectively a few minutes, a few days, fifteen days, twenty-eight years, 
and fifteen years (still living). The two female twins lived one day, 
and eight months. — Ed.] 

Class D. — Monstrosities of class D, in which the heads are united, 
the bodies being distinct, appear to be the most uncommon of all ; and 
I can find the description of delivery in only two cases. One of these 
gave rise to great difficulty ; the labor in the other was easy. We 
should scarcely anticipate much difficulty in the birth of monsters of 
this type ; for, if the head presented and would not pass, we should 
naturally perform craniotomy ; and if the bodies came first, the delivery 
of the monstrous head could readily be accomplished by perforation. 

The result to the mothers in all these cases seems to have been 
very favorable. There is only one in which the death of the mother 
is recorded ; and although in many the result is not mentioned,, we 
may fairly assume that recovery took place. 

Among difficulties in labor, some of the most important are due to 
morbid conditions of the foetus itself. 

Intra-uterine Hydrocephalus. — Of these, the most common, as 
well as the most serious, is caused by intra-uterine hydrocephalus 
(giving rise to a collection of watery fluid within the cranium), by 
which the dimensions of the child's head are enormously increased, 
and the due relations between it and the pelvic cavity entirelv de- 
stroyed (Fig. 133). 

Fortunately this disease is of comparatively rare occurrence, for it is 
one of great gravity both as regards the mother and child. As regards 
the mother, the serious character of the complication is proved by the 
statistics of Dr. Thomas Keith, then of Edinburgh, Avho found that out 
of seventy-four cases no less than sixteen were accompanied by rupture 
of the uterus. The reason of the danger to which the mother is 
subjected is obvious. In some few cases, indeed, the head is so com- 
pressible that, provided the amount of contained fluid be small, it may 
be sufficiently diminished in size, by the moulding to Avhich it is sub- 
jected, to admit of its being squeezed through the pelvis. [ J ] In the 
majority of cases, however, the size of the head is too great for this 
to occur. The uterus therefore exhausts itself, and may even rupture, 

P I once removed a measured pint of hydrocephalic serum from a foetus that was born dead, 
without assistance.— Ed.] 



388 



LABOR 



in the vain endeavor to overcome the obstacle ; while the large and 
distended head presses firmly on the cervix, or on the pelvic tissues, 
if the os be dilated, and all the evil effects of prolonged compression 
are apt to follow. 



Fig. 133. 




Labor impeded by hydrocephalus. 

Diagnosis. — The diagnosis of intra-uterine hydrocephalus is by no 
means so easy as the description in obstetric works would lead ns to 
believe. It is true that the head is much larger and more rounded in 
its contour than the healthy foetal cranium, and also that the sutures 
and fontanelles are more wide, and admit occasionally of fluctuation 
being perceived through them. Still it is to be remembered that the 
head is always arrested above the brim, where it is consequently high 
up and difficult to reach, and where these peculiarities are made out 
with much difficulty. As a matter of fact, the true nature of the case is 
comparatively rarely discovered before delivery ; thus Chaussier 1 found 
that in more than one-half of the cases he collected, an erroneous 
diagnosis had been made. 

Whenever we meet with a case in which either the history of pre- 
vious labor, or a careful examination, convinces ns that there is no 
obstacle due to pelvic deformity, in which the pains are strong and 
forcing, but in which the head persistently refuses to engage in the 
brim, we may fairly surmise the existence of hydrocephalus. Nothing, 
however, short of a careful examination under anaesthesia, the whole 
hand being passed into the vagina so as to explore the presenting part 
thoroughly, will enable us to be quite sure of the existence of this com- 
plication. Under these circumstances such a complete examination is 
not only justified but imperative ; and, when it has been made, the 
difficulties of diagnosis are lessened, for then we may readily make out 

1 Gazette Medicale, 1834. 



DYSTOCIA FROM FOETUS. 389 

the large round mass, softer and more compressible than the healthy 
head, the widely separated sutures, and the fluctuating fontanel les. 

In a considerable proportion of eases — as many, it is said, as one 
out of five — the foetus presents by the breech. The diagnosis is then 
still more difficult; for the labor progresses easily until the shoulders 
are horn, when the head is completely arrested, and refuses to pass 
with any amount of traction that is brought to bear on it. Even the 
most careful examination may not enable us to make out the cause of 
the delay, for the finger will impinge on the comparatively firm base 
of the skull, and may be unable to reach the distended portion of the 
cranium. At this time abdominal palpation might throw some light 
on the case; for, the uterus being tightly contracted round the head, 
we might be able to make out its unusual dimensions. The wasted and 
shrivelled appearance of the child's body, which so often accompanies 
hydrocephalus, would also arouse suspicion as to the cause of delay. 
On the whole, such cases may be fairly assumed to be less dangerous to 
the mother than when the head presents ; for, in the latter, the soft 
parts are apt to be subjected to prolonged pressure and contusion 
while, in the former, delay does not commence till after the shoulders 
are born, and then the character of the obstacle would be sooner dis- 
covered, and appropriate means earlier taken to overcome it. 

Treatment. — The treatment is simple, and consists in tapping the 
head, so as to allow the cranial bones to collapse. There is the less 
objection to this course, since the disease almost necessarily precludes 
the hope of the child's surviving. The aspirator would draw off the 
fluid effectually, and would at least give the child a chance of life ; 
and, under certain circumstances, the birth of a child who lives for a 
short time only may be of extreme legal importance. More generally 
the perforator will be used, and as soon as it has penetrated, a gush of 
fluid will at once verify the diagnosis. Schroeder recommends that, 
after perforation, turning should be performed, on account of the diffi- 
culty with which the flaccid head is propelled through the pelvis. 
This seems a very unnecessary complication of an already sufficiently 
troublesome case. As a rule, when once the fluid has been evacuated, 
the pains being strong, as they generally are, no delay need be appre- 
hended. Should the head not come down, the cephalotribe may be 
applied, which takes a firmer grasp than the forceps, and enables the 
head to be crushed to a very small size and readily extracted. 

"When the breech presents, the head must be perforated through the 
occipital bone, and generally this may be accomplished behind the ear 
without much difficulty. In a case of Tarnier's the vertebral column 
was divided by a bistoury and an elastic male catheter introduced into 
the vertebral canal, through which the intra-cranial fluid escaped, the 
labor being terminated spontaneously. 1 In any case in which it is 
found difficult to reach the skull with the perforator this procedure 
should certainly be tried. 

Other forms of dropsical effusion may give rise to some diffi- 
culty, but by no means so serious. In a few rare cases the thorax has 

1 Hergott : Maladies Foetales qui peuvent faire obstacle k l'accoucheraent. Paris, 1878. 



390 LABOR. 

been so distended with fluid as to obstruct the passage of the child. 
Ascites is somewhat more common, aud occasionally the child's bladder 
is so distended with urine as to prevent the birth of the body. The 
existence of any of these conditions is easily ascertained ; for the head 
or breech, whichever happens to present, is delivered without difficulty, 
and then the rest of the body is arrested. This will naturally cause 
the practitioner to make a careful exploration, when the cause of the 
delay will be detected. 

The treatment consists in the evacuation of the fluid by puncture. 
In the case of ascites, this should always be done, if possible, by a 
fine trocar or aspirator, so as not to injure the child. This is all the 
more important since it is impossible to distinguish a distended bladder 
from ascites, and an opening of any size into that viscus might prove 
fatal, whereas aspiration would do little or no harm, and would prove 
quite as efficacious. 

Foetal Tumors Obstructing* Delivery. — Certain foetal tumors may 
occasion dystocia, such as malignant growths, or tumors of the kidney, 
liver, or spleen. Cases of this kind are recorded in most obstetric 
works. Hydro encephalocele, or hydro-rhachitis, depending on defective 
formation of the cranial or spinal bones, with the formation of a large 
protruding bag of fluid, is not very rare. The diagnosis of all such 
cases is somewhat obscure, nor is it possible to lay down any definite 
rales for their management, which must vary according to the par- 
ticular exigencies. The tumors are rarely of sufficient size to prove 
formidable obstacles to delivery, and inany of them are very com- 
pressible. This is specially the case with the spina bifida and similar 
cystic growths. Puncture — and, in the more solid growths of the 
abdomen or thorax, evisceration — may be required. 

Other deformities, such as the anencephalous foetus, or defective 
development of the thorax or abdominal parietes with protrusion of 
the viscera, are not likely to cause difficulty ; but they may much 
embarrass the diagnosis by the strange and unusual presentation that 
is felt. If, in any case of doubt, a full and careful examination be 
undertaken, introducing the whole hand if necessary, no serious mis- 
take is likely to be made. 

Dystocia from Excessive Development of the Foetus. — In 
addition to dystocia from morbid conditions of the foetus, difficulties 
may arise from its undue development, and especially from excessive 
size and advanced ossification of the skull. This last is especially 
likely to cause delay. Even the slight difference in size between the 
male and female head was found by Simpson to have an appreciable 
effect in increasing the difficulty of labor, when the statistics of a 
large number of cases were taken into account ; for he proved, beyond 
doubt, that the difficulties and casualties of labor occurred in decidedly 
larger proportion in male than in female births. Other circumstances, 
besides sex have an important effect on the size of the child. Thus 
Duncan and Hecker have shown that it increases in proportion to the 
age of the mother and the frequency of the labors ; while the size of 
the parents has no doubt also an important bearing on the subject. 

Although these influences modify the results of labor en masse, they 



DEFORMITIES OF THE PELVIS. 391 

have little or no practical bearing on any particular case, since; it is 

impossible to estimate either the size of the head or the degree of its 
ossification until labor is advanced. 

Treatment. — When labor is retarded by undue ossification or large 
size of the head, the case must be treated on the same general principles 
which guide us when the want of proportion is caused by pelvic con- 
traction. Hence, if delay arise which the natural powers are insuffi- 
cient to overcome, it will seldom happen that the disproportion is too 
great for the forceps to overcome. If we fail to deliver by it, no 
resource is left but perforation. 

Large si/e of the body of the child is still more rarely a cause of 
difficulty ; for, if the head be born, the compressible trunk will almost 
always follow. Still, a few authentic eases are on record in which it 
was found impossible to extract the foetus on account of the unusual 
bulk of its shoulders and thorax. Should the body remain firmly 
impacted after the birth of the Lead, it is easy to assist its delivery by 
traction on the axilla?, by gently aiding the rotation of the shoulders 
into the antero-posterior diameter of the pelvic cavity, and, if neces- 
sary, by extracting the arms, so as to lessen the bulk of the part of 
the body contained in the pelvis. Hicks relates a ease in which 
evisceration was required for no other apparent reason than the 
enormous size of the body. The necessity for any such extreme 
measure must, of course, be of the greatest possible rarity ; and it is 
quite exceptional for difficulty from this source to be beyond the 
powers of Nature to overcome. 



CHAPTEE XII. 

DEFORMITIES OF THE PELVIS. 

Deformities of the Pelvis form one of the most important subjects 
of obstetric study, for from them arise some of the gravest difficulties 
and dangers connected with parturition. A knowledge, therefore, of 
their causes and effects, and of the best mode of detecting them, either 
during or before labor, is of paramount necessity ; but the subject is 
far from easy, and it has been rendered more difficult than need be, 
from over-anxiety on the part of obstetricians to force all varieties of 
pelvic deformities within the limits of their favorite classification. 

Difficulties of Classification. — Many attempts in this direction 
have been made, some of which are based, on the causes on which the 
deformities depend, others on the particular kind of deformity pro- 
duced. The changes of form, however, are so various and irregular, 
and similar, or apparently similar, causes so constantly produce dif- 



392 LABOR. 

ferent effects, that all such endeavors have been more or less unsuc- 
cessful. For example, we find that rickets (of all causes of pelvic 
deformity the most important) generally produces a narrowing of the 
conjugate diameter of the brim ; while the analogous disease, osteo- 
malacia, occurring in adult life, generally produces contraction of the 
transverse diameter, with approximation of the pubic bones, and rela- 
tive or actual elongation of the conjugate diameter. We might, 
therefore, be tempted to classify the results of these two diseases under 
separate heads, did we not find that, when rickets affects children who 
are running about, and subject to mechanical influences similar to 
those acting upon patients suffering from osteomalacia, a form of 
pelvis is produced hardly distinguishable from that met with in the 
latter disease, which by some authors is described as the pseudo- 
osteomalacic. 

On the whole, therefore, the most simple, as well as the most 
scientific, classification is that which takes as its basis the particular 
seat and nature of the deformity. Let us first glance at the most 
common causes. 

Causes of Pelvic Deformity. — The key to the particular shape 
assumed by a deformed pelvis will be found in a knowledge of the 
circumstances which lead to its regular development and normal shape 
in a state of health. The changes produced may, almost invariably, 
be traced to the action of the same causes which produce a normal 
pelvis, but which, under certain diseased conditions of the bones or 
articulations, induce a more or less serious alteration in form. These 
have been already described in discussing the normal anatomy of the 
pelvis, and it will be remembered that they are chiefly the weight of 
the body, transmitted to the iliac bones through the sacro-iliac joints, 
and counter-pressure on these, acting through the acetabula. Some- 
times they act in excess on bones which are healthy, but possibly 
smaller than usual, and the result may be the formation of certain 
abnormalities in the size of the various pelvic diameters. At other 
times they operate on bones which are softened and altered in texture 
by disease, and which, therefore, yield to pressure far more than 
do healthy bones. 

Rickets and Osteomalacia. — The two diseases which chiefly oper- 
ate in causing deformity are rickets and osteomalacia. Into the 
essential nature and symptomatology of these complaints it would be 
out of place to enter here ; it may suffice to remind the reader that 
they are believed to be pathologically similar diseases, with the im- 
portant practical distinction that the former occurs in early life, before 
the bones are completely ossified, and that the latter is a disease of 
adults, producing a softening in bones that have been hardened and 
developed. This difference affords a ready explanation of the gener- 
ally resulting varieties of pelvic deformity. 

Rickets commences very early in life, sometimes, it is believed, even 
in utero. It rarely produces softening of the entire bones, and only 
in case of very great severity, of those parts of the bones that have 
been already ossified. The effects of the disease are principally 
apparent in the cartilaginous portions of the bones, in which osseous 



DEFORMITIES OF THE PELVIS. 393 

deposit has not yel taken place. The bones, therefore, are not subject 
to uniform change, and this fad has an important influence in 
determining their shape. Rickety children also nave imperfect mus- 
cular development ; they do not run about in the same way as other 
children, they are often continuously in the recumbent or sitting pos- 
ture, and thus the weight of the trunk is brought to bear, more than 
in a state of health, on the softened bones. For the same reason 
counter-pressure through the acetabula is absent, or comparatively 
slight. When, however, the disease occurs for the first time in chil- 
dren who are able to run about, the latter comes into operation, and 
modifies the amount and nature of the deformity. It is to be observed 
that in rickety children the bones are not only altered in form from 
pressure, but are also imperfectly developed, and this materially 
modifies the deformity. Wheu ossific matter is deposited, the bones 
become hard and cease to bend under external influences, and retain 
for ever the altered shape they have assumed. 

Osteomalacia. — In osteomalacia, on the contrary, the already 
hardened bones become softened uniformly through all their tex- 
tures, and thus the changes which are impressed upon them are 
much more regular and more easily predicated. It is, however, an 
infinitely less common cause of pelvic deformity than rickets, as is 
evidenced by the fact that in the Paris Maternity, in a period of 
sixteen years, 402 cases of deformity due to rickets occurred to one 
due to osteomalacia. 1 

Their Varying* Frequency. — The frequency of both diseases varies 
greatly in different countries and under different circumstances. 
Rickets is much more common amongst the poor of large cities, whose 
children are ill-fed, badly-clothed, kept in a vitiated atmosphere, and 
subjected to unfavorable hygienic conditions. Deformities are there- 
fore more common in them than in the more healthy children of 
the upper classes or of the rural population. The higher degrees of 
deformity, necessitating the Csesarean section or craniotomy, are in 
England of extreme rarity ; while in certain districts on the Con- 
tinent they seem to be so frequent that these ultimate resources of the 
obstetric art have to be constantly employed. 

[Osteomalacia is so rare in the United States that very few ob- 
stetricians with large experience have ever met with a case ; and but 
one is on record w T here the disease produced a deformity that required 
delivery by the abdomen, and this woman was not a native. 

Rickets is becoming much more common among the poor of our 
large cities, and especially in the black race, in w r hom it may be 
readily recognized by their convex flattened tibiae and projecting 
heels; as also by their peculiar gait, which is most marked in running. 
The peculiar long-flattened head of the African foetus enables a 
mother with a slightly deformed pelvis, in many instances, either to 
deliver herself or to escape abdomino-uterine section by aid of the 
forceps. — Ed.] 

In another class of cases the ordinary shape is modified by weight 

1 Stanesco : Recherches cliniqucs sur les Retrecissements du Bassin. 



394 LABOR. 

and counter-pressure operating on a pelvis in which one or more of 
the articulations is ossified. In this way we have produced the 
obliquely ovate pelvis of Naegele, or the still more uncommon trans- 
versely contracted pelvis of Robert. 

Other Causes of Pelvic Deformity. — A certain number of de- 
formed pelves cannot be referred to a modification of the ordinary 
developmental changes of the bones. Amongst these are the deform- 
ities resulting from spondylolisthesis, or downward dislocation of the 
lower lumbar vertebrae ; from displacements of the sacrum, caused by 
curvatures of the spinal column, producing the kyphotic and scoliotic 
pelves ; or from diseases of the pelvic bones themselves, such as 
tumors, malignant growths, and the like. 

The first class of deformed pelves to be considered is that in which 
the diameters are altered from the usual standard, without any definite 
distortion of the bones ; and such are often mere congenital variations 
in size, for which no definite explanation can be given. Of this class 
is the pelvis which is equally enlarged in all its diameters {'pelvis 
oy.quabiliter justo major), which is of no obstetric consequence, except 
inasmuch as it may lead to precipitate labor, and is not likely to be 
diagnosed during life. 

The corresponding diminution of all the pelvic diameters [pelvis 
aequabiliter justo minor) may be met with in women who are apparently 
well-formed in every respect, and whose external conformation and 
previous history give no indication of the abnormality. Sometimes 
the diminution amounts to half an inch or more, and it can readily be 
understood that such a lessening in the capacity of the pelvis would 
give rise to serious difficulty in labor. Thus, in three cases recorded 
by N" aegele a fatal result followed ; in two after difficult instrumental 
delivery, and in the third after rupture of the uterus. The equally 
lessened pelvis, however, is of great rarity. An unusually small pelvis 
may be met with in connection with general small size, as in dwarfs. 
It does not necessarily follow, because a woman is a dwarf, that the 
pelvis is too small for parturition. On the contrary, many such 
women have borne children without difficulty. 

[We may be greatly deceived by the external characteristics of a 
large and tall woman as to the presumed development of her pelvis, 
and be led to credit her with diameters far beyond the actual measure- 
ments. In a lady above the average height, with large hips and now 
weighing over two hundred pounds, I found a vagina which the index 
finger entered with difficulty, and with a pelvis so small that it is 
doubtful if she could be delivered of a living fcetus much over seven 
months. She bore one child at maturity, which was delivered after 
its death with a crushed head, at the end of three days' labor and after 
long and powerful traction by compressing forceps. She has a true 
justo minor pelvis. — Ed.] 

In some cases a pelvis retains its infantile characteristics after 
puberty (Fig. 134). The normal development of the pelvis has been 
interfered with, possibly from premature ossification of the different 
portions of the innominate bones, or from arrest of their growth from 
a weakly or rhachitic constitution. The measurements of these pelves 



DEFORMITIES OF THE PELVIS. 395 

are not always below the normal standard ; they may continue to 
grow, although they have not developed. The proportionate measure- 
ments i)!' the various diameters will then be as in the infant ; and the 
anteroposterior diameter may he longer, or as long as the transverse, 
the ischia comparatively near each other, and the pubic arch narrow. 
Such a form of pelvis will interfere with the mechanism of delivery, 
and unusual difficulty in labor will be experienced. Difficulties from 
a similar cause may be expected in very young girls. Here, however, 
there is reason to hope that, as age advances, the pelvis will develop 
and subsequent labors be more easy. 

Fig. 134. 




Adult pelvis retaining its infantile type. 

The masculine, or funnel-shaped, pelvis owes its name to its approxi- 
mation to the type of the male pelvis. The bones are thicker and 
stouter than usual, the conjugate diameter of the brim longer, and the 
whole cavity rendered deeper and narrower at its lower part by the 
nearness of the ischial tuberosities. It is generally met with in strong 
muscular women following laborious occupations, and Dr. Barnes, 
from his experience in the Royal Maternity charity, says that it chiefly 
occurs in weavers in the neighborhood of Bethnal Green, who spend 
most of their time in the sitting posture. 

"The cause of this form of pelvis seems to be an advanced condition 
of ossification in a pelvis which would otherwise have been infantile, 
brought about by the development of unusual muscularity, correspond- 
ing to the laborious employment of the individual." The difficulties in 
labor will naturally be met with toward the outlet, where the funnel 
shape of the cavity is most apparent. 

Diminution of the antero-posterior diameter {flattened pelvis) is most 
frequently limited to the brim, and is by far the most common variety 
of pelvic deformity. In its slighter degrees it is not necessarily de- 
pendent on rickets, although when more marked it almost invariably 
is so. When unconnected with rickets it probably can be traced to 
some injurious influence before the bones have ossified, such as increased 



396 



LABOK. 



pressure of the trunk, from carrying weights in early childhood, and 
the like. By this means the sacrum is unduly depressed, and projects 
forward, so as to slightly narrow the conjugate diameter. 

Mode of Production in Rickets. — When caused by rickets the 
amount of the contraction varies greatly, sometimes being very slight, 
sometimes sufficient to prevent the passage of the child altogether, and 
necessitate craniotomy or the Cesarean section. The sacrum, softened 
by the disease, is pressed vertically downward by the weight of the 
body, its descent being partially resisted by the already ossified por- 
tions of the bone, so that the result is a downward and forward move- 
ment of the promontory. The upper portion of the sacral cavity is 

Fig. 135. 




Scolio-rhachitic pelvis. (From a specimen in the Museum of St. Bartholomew's Hospital.) 

thus directed more backward ; but, as the apex of the bone is drawn 
forward by the attachment of the perineal muscles to the coccyx, and 
by the sacro-ischiatic ligaments, a sharp curve of its loAver part in a 
forward direction is established. The horizontal rami of the pubes 
are also flattened, while the ischia are more widely separated than in a 
normal pelvis, thus producing a greater width of the pubic arch, while 
the acetabula are turned forward. 

The depression of the sacral promontory would tend to produce 
strong traction, through the sacro-iliac ligaments, on the posterior end 
of the sacro-cotyloid beams, and thus induce expansion of the iliac 
bones, and consequent increase of the transverse diameter of the brim. 
So an unusual length of the transverse diameter (t) is very often de- 
scribed as accompanying this deformity, but probably it is not so often 
apparent as might otherwise be expected, on account of the imperfect 
development of the bones generally accompanying rickets ; and Barnes * 



Lectures on Obst. Operations, p. 280. 



DEFORMITIES OF THE PELVIS. 397 

says that in parts of London where deformities are most rife, any 
enlargement of the transverse diameter is exceedingly rare. 

Frequently the sacrum is not only depressed, but displaced more or 
less to one side, most generally to the left, thus interfering with the 
regular shape of the deformed brim. This is often the result of 
a lateral flexion of the spinal column, depending on the rhachitic 
diathesis, and when well marked is known as the scolio-rhachitic pelvis 
(Fig. 135), in which one side of the pelvis, that corresponding to the 
direction of the spinal curve, is asymmetrical and contracted, the ilio- 
pectineal line being sharply curved inward about the site of the sacro- 
iliac synchondrosis, the symphysis pubis being displaced toward the 
opposite side. A somewhat similar, but much less marked, unilateral 
asymmetry may exist in cases of scoliosis unconnected with rickets, 
but rarely to a sufficient degree to interfere materially with labor. 

In most cases of this kind the cavity of the pelvis is not diminished 
in size, and is often even more than usually wide. The constant 

Fig. 136. 




Rickety pelvis, with backward depression of symphysis pubis. 

pressure on the ischia, which the sitting posture of the child entails, 
tends to force them apart, and also to widen the pubic arch, Con- 
siderable advantage results from this in cases in which we have to 
perform obstetric operations, as it gives plenty of room for manipu- 
lation. 

Fig-ure-of-eig-ht Deformity. — In a few exceptional cases the nar- 
rowing of the conjugate diameter is increased by a backward depression 
of the symphysis pubis, which gives the pelvic brim a sort of figure- 
of-eight shape (Fig. 136). The most reasonable explanation of this 
peculiarity seems to be that it is the result of the muscular contraction 
of the recti muscles, at their point of attachment, when the centre of 
gravity of the body is thrown backward, on account of the projection 
of the sacral promontory. Sometimes also the antero-posterior diam- 
eter of the cavity is unusually lessened by the disappearance of the 
vertical curvature of the sacrum, which, instead of forming a distinct 
cavity, is nearly flat (Fig. 137). 

Spondylolisthesis. — In a few rare cases, to which attention was 
first called in 1853 by Kilian, of Bonn, a very formidable narrowing 
of the conjugate diameter of the pelvic brim is produced by a down- 
ward displacement of the fourth and fifth lumbar vertebrae, which 



398 



LABOR. 



become dislocated forward, or, if not actually dislocated, at least separ- 
ated from their several articulations to a sufficient extent to encroach 
very seriously on the dimensions of the pelvic inlet. This condition 
is known as spondylolisthesis (Fig. 138). 



Fig. 137. 



Fig. 138. 





Flatness of sacrum, with narrowing of 
pelvic cavity. 



Pelvis deformed by spondylolisthesis. 
(After Kilian.) 



The effect of this is sufficiently obvious, for the projection of the 
lumbar vertebrae prevents the passage of the child. To such an extent 
is obstruction thus produced, that, in the majority of the recorded 
cases, the Cesarean section was necessary. The true conjugate diameter, 
that between the promontory of the sacrum and the symphysis pubis, 
is increased rather than diminished ; but, for all practical purposes, 
the condition is similar to extreme narrowing of the conjugate from 
rickets, for the bodies of the displaced vertebrae project into and ob- 
struct the pelvic brim. 

The cause of this deformity seems to be different in different cases. 
In some it seems to have been congenital, and in others to have de- 
pended on some antecedent disease of the bones, such as tuberculosis 
or scrofula, producing inflammation and softening of the connection 
between the last lumbar vertebra and the sacrum, thus permitting 
downward displacement of the bones. Lambl believed that it gener- 
ally followed spina bifida, Avhich had besome partially cured, but 
which had produced deformity of the vertebrae, and favored their dis- 
location. Brodhurst, 1 on the other hand, thinks that it most probably 
depends on rhachitic inflammation and softening of the osseous and 
ligamentous structures, and that it is not a dislocation in the strict sense 
of the word. This condition has recently been made the subject of 
special study by Dr. Frangois Neugebauer, 2 who believes that the for- 
ward displacement is never the result of antecedent disease of the 
bones, but depends either on congenital want of development of the 



1 Obst. Trans.. 1865, vol. vi. p. 97. 

2 Contribution a la Pathogenie du Bassin vicie par le Glissenient Vertebral. Paris, 1884. 



DEFORMITIES OF THE PELVIS. 



399 



vertebral arches, or on traumatism, such as fracture of the articular 
processes, which allows the weight of the trunk to displace the body of 
the iast lumbar vertebra forward, either partially or entirely. 

[We are indebted to Kilian, of Bonn, Germany, for the first careful 
investigation of the true character of spondylolisthetic deformity, 
although the credit of initial men- 
tion is due to Rokitansky, of t FlG - 189 - 
Austria, who wrote in 1839, ante- 
dating the monograph of the 
former (1853) by fourteen years. 
No special mention is made of 
this peculiar lordosis by Roki- 
tansky in his Manual of Patho- 
logical Anatomy in 1844, but in 
his Lehrbueh (1855) it is given, 
with due credit to Kilian. Dur- 
ing the thirty -three years that 
have passed since Kilian prepared 
his paper from observations made 
upon three pelves which had been 
obtained from subjects in whom 
the Cesarean section had proved 
fatal, one of them after a second 
operation, there have appeared 
numerous monographs and de- 
scriptions of cases, much the most 
valuable and extensive of which are those by Dr. Franz Ludwig 
Neugebauer, of Warsaw, and Dr. A. Swedelin, of St. Petersburg, the 
latter of whom furnishes the bibliography of the subject. These 
valuable papers cover 223 and 40 pages respectively of the Archiv fur 
Gyndkologie, Berlin, vols, xix., xx., xxi., xxii., and xxv., for 1882-85. 

The most frequent origin of spondylolisthetic deformity appears to 
lie in an incomplete ossification of the last lumbar vertebra, whereby 
its anterior and posterior portions are rendered liable to separate under 
the superincumbent weight of the body. Hence the subjects of the 
slipping are frequently stout, heavy women. This was markedly the 
case in the woman who came under the care of Prof. James Blake, of 
San Francisco. 1 This patient was married at fifteen years of age, at 
which time she weighed 101 pounds, but increased to 199 pounds by 
the time her first child was born. Her first and second labors were 
tedious, but the children were born alive ; she aborted of another foetus 
at four months, and later was delivered at maturity of four others, all 
dead, the conjugate space in the seventh labor being computed at three 
and a half inches. This labor was so difficult that it was decided, in 
the event of another pregnancy, to bring on labor prematurely. She 
became pregnant for the eighth time at the age of twenty-six, when 
she weighed 220 pounds. Labor was induced in the seventh month, 
but the foetus was lost, as it weighed nearly six pounds and the lumbo- 




Spondylolisthesis. (After NErGEBAUER.)] 



t 1 Pac. Med. and Surg. Joum., Feb. 1867.] 



400 LABOR. 

pubic space was reduced to three inches. This woman is said to have 
undergone the change in her vertebrae without pain or sign of ill- 
health, and to have retained a remarkable activity for her weight. 
After her eighth delivery she was up in six days and downstairs in 
ten. The history of this case would indicate that the deforming pro- 
cess must have been slowly progressing during more than ten years. 

In contrast with this painless case in a multipara we have the oppo- 
site in a nullipara, reported by Dr. Olshausen, formerly of Halle. 
The disease commenced in his patient when a girl of eighteen, with 
severe pains in the sacrum and hips, as in malacosteon. She had not 
had rickets in childhood, had enjoyed good health up to this time, and 
was quite straight. As her disease progressed she found on awaking 
one morning that she could not straighten her spine, and was forced 
to walk with her body bent forward. She was put under medical 
treatment at the surgical clinic ; had no fever, and in time ceased to 
suffer, and was discharged. Becoming pregnant at the age of twenty- 
four, Dr. Olshausen delivered her in 1863 by the Caesarean section ; 
the child lived, but she was lost on the fourth day by peritonitis. 
The lumbo-pubic diameter was found to measure three inches, and the 
line of the conjugate struck the lower margin of the third lumbar 
vertebra. 

Spondylolisthesis is of very great rarity in our country — so much so 
that I know of but one case delivered under the Conservative Cesarean 
section ; this was performed by Dr. Hal C. TTyinan, at Detroit, on 
January 19, 1891, the woman having been in labor three days. The 
child was lost, and the mother died in forty-eight hours, of pulmonary 
oedema and cyanosis. — Ed.] 

Spondylolizema. — A somewhat analogous deformity has been 
described by Hergott 1 under the name of Spondylolizema. In this the 
bodies of the lower lumbar vertebrae having been destroyed by caries, 
the upper lumbar vertebrae sink downward and forward, so as to 
obstruct the pelvic inlet and prevent the engagement of the foetus. 
It thus differs from spondylolisthesis, in which there is dislocation, 
but not destruction, of the bodies of the lower lumbar vertebrae. 

Deformity from Osteomalacia. — The most marked examples of 
narrowing of both oblique diameters depend on osteomalacia. In this 
disease, as has already been remarked, the bones are uniformly softened, 
and the alterations in form are further influenced by the fact that the 
disease commences after union of the separate portions of the ossa 
innominata has been completely effected. The amount of deformity 
in the AA'orst cases is very great, and frequently renders delivery im- 
possible without the Caesarean section. Sometimes the softening of 
the bones proves of service in delivery by admitting of the dilatation 
of the contracted pelvic diameter by the pressure of the presenting 
part, or even by the hand. Some curious cases are on record in which 
the deformity was so great as to apparently require the Caesarean sec- 
tion, but in which the softened bones eventually yielded sufficiently to 
render this unnecessary. 

1 Arch, de Tocologie, 1877, p. 65. 



DEFORMITIES OF THE PELVIS. 



401 



The weight of the body depresses (lie sacrum in ii vertical direction, 
and at the same time compresses its component parts together, so as to 
approximate the base and apex of the bone, and narrow the conjugate 
diameter of the brim, by causing the promontory to encroach upon it. 



Fig. 140. 




Osteomalacic pelvis. 



The most characteristic changes are produced by the pushing inward 
of the walls of the pelvis at the cotyloid cavities, in consequence of 
pressure exerted at these points through the femora. The effect of this 
is to diminish both oblique diameters, giving the brim somewhat the 
shape of a trefoil, or an ace of clubs. The sides of the pubes are at 



Fig. 141. 




Extreme degree of osteomalacic deformity. 

the same time approximated, and may become almost parallel, and the 
true conjugate may be even lengthened (Fig. 140). The tuberosities 
of the ischia are also compressed together, with the rest of the lateral 
pelvic wall, so that the outlet is greatly deformed as well as the brim. 
(Fig. 141). 

Obliquely Contracted Pelvis. — That form of deformity in which 
one oblique diameter only is lessened has received considerable atten- 

26 



402 LABOR. 

tion, from having been made the subject of special study by Naegele, 
and is generally known as the obliquely contracted pelvis (Fig. 142). It 
is a condition that is very rarely met with, although it is interesting 
from an obstetric point of view, as throwing considerable light on the 
mode in which the natural development of the pelvis is effected. It is 
difficult to diagnose, inasmuch as there is no apparent external de- 
formity, and probably it has never, in fact, been detected before 
delivery. It has a very serious influence on labor ; Litzmann found 
that out of twenty-eight cases of this deformity, twenty-two died in 
their labors, and five more in subsequent deliveries. The prognosis, 
therefore, is very formidable, and renders a knowledge of this distor- 
tion, rare though it be, of importance. 

Its essential characteristic is flattening and want of development of 
one side of the pelvis, associated with ankylosis of the corresponding 

sacro-iliac synchondrosis. The latter 
FlG - 142 - is probably always present, and it 

seems to be most generally a con- 
genital malformation. The lateral 
half of the sacrum on the same side, 
and the entire innominate bone, are 
much atrophied. The promontory of 
the sacrum is directed toward the 
diseased side, and the symphysis pubis 
is pushed over toward the healthy 
side.p] 

The main agent in the production 
^msssm&tr of this deformity is the absence of the 

Obliquely contracted pelvis. (After .,. . . J , . , 

Duncan.) sacro-iliac joint, which prevents the 

proper lateral expansion of the pelvic 
brim on that side, and allows the counter-pressure through the femur 
to push in the atrophied os innominatum to a much greater extent than 
usual. The chief diminution in the length of the pelvic diameter is 
between the ilio-pectineal eminence of the aifected side and the healthy 
sacro-iliac joint ; while the oblique diameter between the ankylosed 
joint and the healthy os innominatum is of normal length. 

[Coxalgia in little girls, affecting one joint, not only stunts the 
growth of the lower extremity, but that of the ilium as well, making the 
superior strait D -shaped ; the linea ilio-pectinea having but little curve 
on the ankylosed side. Such cases have several times required 
Cesarean delivery in this country. — Ed.] 

Narrowing- of the Transverse Diameter. — Transverse contraction 
of the pelvic brim is very much less common than narrowing of the 
conjugate diameter. It most frequently depends on backward curvature 
of the lower parts of the spinal column, in consequence of disease of 
the vertebrae. This form of deformed pelvis is generally known as 
the kyphotic (Fig. 143). The effect of the spinal curvature is to drag 
the promontory of the sacrum backward, so that it is high up and out 
of reach. By this means the antero-posterior diameter of the brim is 

t 1 It was for this form of pelvis that Pinard, of Paris, performed, with success, the operation of 
unilateral pubio-ischiotomy.— En.] 




DEFORMITIES OF THE PELVIS 



403 



increased, while the transverse is lessened ; the relative proportion 
between the two is thus reversed. While the upper portion of the 
sacrum is displaced backward, its lower end is projected forward, so 



Fig. 143. 




Fig. 



Kyphotic pelvis. (From a specimen in the Museum of St. Bartholomew's Hospital.) 

that the antero-posterior diameters of the cavity and outlet are con- 
siderably diminished. The ischial tuberosities are also nearer to each 
other, and the pubic arch is narrowed. Obstruction to delivery will 
be chiefly met with at the lower parts 
and outlet of the pelvic cavity ; 
for, although the transverse diam- 
eter of the brim is narrowed, there 
is generally sufficient space for the 
passage of the head. 

Robert's Pelvis. — Another form 
of transversely contracted pelvis is 
known as Robert's pelvis (Fig. 144), 
having been first discovered by 
Robert, of Coblentz. It is in fact a 
double obliquely contracted pelvis, 
depending on ankylosis of both 
sacro-iliac joints, and consequent de- 
fective development of the innomi- 
nate bones. The shape of the pelvic brim is markedly oblong, and 
the sides of the pelvis are more or less parallel with each other. The 




Robert's, or double obliquely contracted 
pelvis. (After Duncan.) 



404 



LABOR 



Fig. 146. 



outlet is also much contracted transversely. The amount of obstruc- 
tion is very great, so that, according to Schroeder, out of seven well- 
authenticated cases, the Cesarean section was required in six. 

Deformity from Old-standing" Hip-joint Disease. — Another cause 
of transverse deformity occasionally met with is luxation of the head 
of the femur, depending on old-standing joint disease. The head of 
the femur, in this case, presses on the innominate bone at the site of 
dislocation, and the result is that the iliac fossa on the affected side, or 
both if the accident happens on both sides, is pushed inward, the 
transverse diameter of the brim being lessened. The tuberosity of 
the ischium is, ho ver, projected outward, so that the outlet of the 
pelvis is increased rather than diminished. 

Deformity from Tumors, Fractures, etc. — Obstruction of the 
pelvic cavity from exostoses or other forms of tumors growing from 
the bones is of great rarity (Fig. 145). It may, however, produce 
very serious dystocia. Several curious examples are collected in Mr. 

Wood's article on the pelvis, in some 
of which the obstruction was so great 
as to necessitate the Cesarean section. 
Some of these growths were true 
exostoses, and according to Stad- 
feldt, 1 these are commonly found in 
pelves that are otherwise contracted ; 
others, osteo-sarcomatous tumors at- 
tached to the pelvic bones, most 
generally the upper part of the 
sacrum ; and others were malignant. 
In some cases spicule of bone have 
developed about the linea ilio-pec- 
tinea or other parts of the pelvis, 
which may not be sufficient to pro- 
duce obstruction, but which may 
injure the uterus, or even the foetal 
head, when they are pressed upon 
them. Irregular projections may 
also arise from the callus of old 
fractures of the pelvic bones. All 
such cases defy classification and differ so greatly in their extent, and 
in their effect on labor, that no rules can be laid down for them, and 
each must be treated on its own merits. 

The effects of pelvic contractions on labor vary, of course, 
greatly with the amount and nature of the deformity ; but they must 
always give rise to anxiety, and in the graver degrees they produce 
the most serious difficulties we have to contend with in the whole 
range of obstetrics. 

In the lesser degrees, in which the proportion between the present- 
ing part and the pelvis is only slightly altered, we may observe little 
abnormal beyond a greater intensity of the pains, and some protraction 




Bony growth from sacrum obstructing the 
pelvic cavity. 



i Obst. Journ., 1879-80, vol. vii. p. 201. 



DEFORMITIES OF THE PELVIS. 405 

of the labor, [t is generally observed thai the uterine contractions 
are strong and forcible in cases of this kind, probably because of* the 
increased resistance they have to contend against; and this is obviously 
a desirable and conservative occurrence, which may, of itself, suffice 
to overcome the difficulty. The firsl stage, however, is not unfre- 
qnently prolonged, and the pains are ineffective, for the head does not 
readily engage in the brim, the uterus is more mobile than in ordinary 
labors, and it probably acts at a disadvantage. 

Risk to the Mother. — In the more serious cases, the mother is 
subjected to many risks, directly proportionate to the amount of 
obstruction and the length of the labor. The long-continued and 
excessive uterine action, produced by the vain endeavors to push the 
child through the contracted pelvic canal, the more or less prolonged 
contusion and injury to which the maternal soft parts are necessarily 
subjected (not unfrequently ending in inflammation and slonghing 
with all its attendant dangers), and the direct injury which may be 
inflicted by the measures we are compelled to adopt for aiding delivery 
(such as the forceps, turning, craniotomy, or Cesarean section), ail 
tend to make the prognosis a matter of grave anxiety. [The Cesarean 
operation has been performed ten times in the United States in cases 
of pelvic exostosis, with five recoveries. One woman was operated 
upon three times and died from the third operation ; five of the ten 
children were saved. Of the fatal cases, three were in labor three 
days; one, two days; in one, labor was induced; and one had been in 
convulsions for twenty-four hours. Of the five that recovered, two 
were in labor " a few hours ;" one, twelve hours ; one, tAventy-four 
hours ; and one, thirty-eight hours. — Ed.] 

Risk to the Child. — Xor are the dangers less to the child ; and a 
very large proportion of stillbirths will always be met with. The 
infantile mortality may be traced to a variety of causes, the most 
important being the protraction of the labor, and the continuous 
pressure to which the presenting part is subjected. For this reason, 
even in cases in which the contraction is so slight that the labor is 
terminated by the natural powers, it has been estimated that one out 
of every five children is stillborn ; and as the deformity increases in 
amount, so, of course, does the prognosis to the child become more 
unfavorable. 

Prolapse of the umbilical cord is of very frequent occurrence 
in cases of pelvic deformity, the tendency to this accident being trace- 
able to the fact of the head not entering and occupying the upper 
strait of the pelvis as in ordinary labors, and thus leaving a space 
through which the cord may descend. So frequently is this compli- 
cation met with in pelvic deformity that Stanesco found it had 
happened as often as fifty-nine times in 414 labors; and when the 
dangers of prolapsed funis are added to those of protracted labors, it 
is hardly a matter of surprise that the occurrence should, under such 
circumstances, almost always prove fatal to the child. 

The head of the child is also liable to injury of a more or less grave 
character, from the compression to which it is subjected, especially by 
the promontory of the sacrum. Independently of the transient effects 



406 LABOR. 

of undue pressure (temporary alteration of the shape of the bones 
and bruising of the scalp), there is often met with a more serious 
depression of the bones of the skull, produced by the sacral promon- 
tory. This is most marked in cases in which the head has been 
forcibly dragged past the projecting bone by the forceps, or after 
turning. The amount of depression varies with the degree of con- 
traction ; but sometimes, were it not for the yielding of the bones of 
the foetal skull in this way, delivery, without lessening the size of the 
head by perforation, w T ould be impossible. Such depressions are found 
at the spot immediately opposite the promontory, generally at the side 
of the skull near the junction of the frontal and parietal bones. 
Sometimes there is a slight permanent mark, but more often the 
depression disappears in a few days. The prognosis to the child is, 
however, grave, when the contraction has been sufficient to indent the 
skull ; for it has been found that 50 per cent, of the children thus 
marked died either immediately or shortly after labor. 1 

Course of Labor. — The means which Nature takes to overcome 
these difficulties are well worthy of study, and there are certain pecu- 
liarities in the mechanism of delivery, when pelvic deformities exist, 
which it is of importance to understand, as they guide us in deter- 
mining the proper treatment to adopt. 

Frequency of Malpresentation. — Malpresentations of the foetus 
are of much more frequent occurrence than in ordinary labors ; partly 
because the head does not engage readily in the brim, but, remaining 
free above it, is apt to be pushed away by the uterine contractions, and 
partly because of the frequent alteration of the axis of the uterine 
tumor. The pendulous condition of the abdomen in cases of pelvic 
deformity is often very obvious, so that the fundus is sometimes 
almost in a line with the cervix, and thus transverse or other abnormal 
positions are very frequently met with. It is to be noted, however, 
that we cannot regard breech presentations as so unfavorable as in 
ordinary labors, for the pressure from the contracted pelvis is less 
likely to be injurious when applied to the body than to the head of 
the child ; and, indeed, as we shall presently see, the artificial pro- 
duction of these presentations is often advisable as a matter of choice. 

Mechanism of Delivery in Head Presentations. — The mode in 
which the head passes naturally through a contracted pelvis is in some 
respects different from the ordinary mechanism of delivery in head 
presentations, and has been carefully worked out by Spiegelberg and 
other German obstetricians. 

The means which Nature adopts to overcome the difficulty are 
different in cases in which there is a marked narrowing of the con- 
jugate diameter of the brim, and in those in which there is a generally 
contracted pelvis. 

a. In Contracted Brim. — In the former, and more common, de- 
formity, the head lies at the brim with its long occipito-frontal diameter 
in the transverse diameter of the pelvis, and, as both parietal bones 
cannot enter the contracted brim, it lies with one parietal bone on 

1 Schroeder, op. cit, p. 256. 



DEFORMITIES OF THE PELVIS 



407 



Fig. 140. 




Head passing through the inlet in 
a flat pelvis. (After Paevin.) 



a much lower level than the other; in the Large majority of cases 
that nearest the pubes being most depressed, so that the sagittal sntnre 
is felt high up near the promontory of the sacrum (Fig. 146). As 
labor advances, if the contraction is not too 
great to be insuperable, the anterior fonta- 
nelle comes much more within reach than 
in ordinary labor, while, at the same time, 
the occipital portion of the head is shoved 
to the side of the pelvis, so that its narrow 
bi-temporal diameter engages in the con- 
tracted conjugate. At this stage, on exami- 
nation, it will be found — stipposing Ave have 
to do with a case in which the occiput points 
to the left side of the pelvis — that the 
anterior fontauelle is lower than the pos- 
terior, and to the right, that the bi-temporal 
diameter of the head is engaged in the con- 
jugate diameter of the brim (as the smallest 
diameter of the skull, there is manifest 
advantage in this), and that the bi- parietal 
diameter and the largest portion of the head 
points to the left side. The sagittal suture 

will be felt running across in the transverse diameter of the brim, but 
nearer to the sacrum, the head being placed obliquely. As the head 
is forced down by the uterine contractions, the parietal bone, which is 
resting on the promontory, is pushed against it, so that the sagittal 
suture is forced more into the true transverse diameter of the pelvic 
brim, and approaches nearer to the pubes. The next step is the 
depression of the head, the occiput undergoing a sort of rotation on 
its transverse axis so that it reaches a plane below the brim. When 
this is accomplished, the rest of the head readily passes the obstruction. 
The forehead now meets with the resistance of the pelvic walls, the 
posterior fontauelle descends to a lower level, 
and, as the cavity of the pelvis in cases of 
antero-posterior contraction of the brim is 
generally of normal dimensions, the rest of 
the labor is terminated in the usual way. 

b. In Generally Contracted Pelvis. — In 
the generally contracted pelvis the head enters 
the brim with the posterior fontanelle lowest, 
and it is after it has engaged in it that the 
resistance to its progress becomes manifest. 
The result is, therefore, an exaggeration of 
what is met with in ordinary cases. The 
resistance to the anterior or longer arm of 
the lever is greater than that to the occipital 
or shorter ; and, therefore, the flexion of 
the head becomes very marked (Fig. 147). 
The posterior fontanelle is consequently unusually depressed, and the 
anterior quite out of reach. So the head is forced down as a wedge, 



Fig. 147. 




Marked flexion of the head 
entering a generally contracted 
pelvis. (After Parvin.) 



408 LABOR. 

and its further progress must depend upon the amount of contraction. 
If this be not too great the anterior fontanelle eventually descends, 
and delivery is completed in the usual way. Should the contraction 
be too much to permit of this, the head becomes jammed in the pelvis, 
and diminution of its size may be essential. 

In cases of deformity of the conjugate diameter combined with 
general contraction of the pelvis, the mechanism partakes of the pecu- 
liarities of both these classes, to a greater or less extent, in proportion 
to the preponderance of one or other species of deformity. 

Diagnosis. — It rarely happens that deformities of the pelvis, except 
of the gravest kind, are suspected before labor has actually commenced, 
and therefore we are not often called upon to give an opinion as to 
the condition of the pelvis before delivery. Should we be so, there 
are various circumstances which may aid us in arriving at a correct 
conclusion. Prominent among them is the history of the patient in 
childhood. If she is known to have suffered from rickets in early 
life, more especially if the disease has left evident traces in deformities 
of the limbs, or in a dwarfed and stunted growth, or in curvature of 
the spine, there will be strong presumptive evidence of pelvic deformity; 
a markedly pendulous state of the abdomen may also tend to confirm 
the suspicion. Nothing short of a careful examination of the pelvis 
itself will, however, clear up the point with certainty ; and even by 
this means, to estimate the precise degree of deformity with accuracy 
requires considerable skill and practice. The ingenuity of practitioners 
has been much exercised — it might perhaps be justly said wasted — in 
the invention of various more or less complicated pelvimeters for aid- 
ing us in obtaining the desired object. It is, however, pretty generally 
admitted by all accoucheurs that the hand forms the best and most 
reliable instrument for this purpose, at any rate as regards the interior 
of the pelvis ; although a pair of callipers, such as Baudelocque's well- 
known instrument, is essential for accurately determining the external 
measurements. The objections to all internal pelvimeters, even those 
most simple in their construction, are their cost and complexity, and 
the impossibility of using them without pain or injury to the patient. 

It was formerly thought that by measuring the distance between the 
spinous processes of the sacrum and the symphysis pubis, and sub- 
tracting from it what we judge to be the thickness of the bones and 
soft parts, we might arrive at an approximate estimate of the measure- 
ment of the conjugate diameter of the pelvic brim. It is now admitted 
that this method can never be depended on, and that, taken by itself, 
it is practically useless. A change in the relative length of other ex- 
ternal measurements of the pelvis is, however, often of great value in 
showing the existence of deformity internally, although not in judging 
of its amount. The measurements which are used for this purpose are 
between the anterior superior spines of the ilia, and between the centres 
of their crests, averaging respectively ten and one-quarter and eleven 
and one-quarter inches in the covered pelvis. According to Spiegel- 
berg, these measurements may give one of three results. 

1. Both may be less than they ought to be, but the relation of one 
to the other remains unchanged. 



DEFORMITIES OF THE PELVIS. 409 

2. That between the crests is not, or is at mosl very little, dimin- 
ished, but that between the spines is increased. 

3. Both are diminished, hut at the same time their mutual relation is 
not normal, the distance between the spines being as long, if not longer, 
than that between the 1 crests. 

No. 1 denotes a uniformly contracted pelvis ; No. '2, a pelvis simply 
contracted in the conjugate diameter of the brim, and not otherwise 
deformed; No. 3, a pelvis with narrowed conjugate and also uniformly 
contracted, as in the severe type of rhachitic deformity. If, however, 
both these measurements are of average length, and the distance be- 
tween the crests is about one inch greater than between the spines, the 
pelvis is normal. 

Besides the above, useful information may be obtained by the meas- 
urement of the external conjugate diameter, which averages seven and 
three-quarters inches, varying somewhat with the amount of adipose 
tissue present. This may be taken by placing one point of the callipers 
in the depression below the spine of the last lumbar vertebra, the other 
at the centre of the upper edge of the symphysis pubis. If the meas- 
urement be distinctly below the average, not more, for example, than 
six and one-quarter inches, we may conclude that there is a consider- 
able narrowing of the antero-posterior diameter of the brim, the extent 
of which we must endeavor to ascertain by other means. If, on the 
other hand, the measurement equals or exceeds the average (seven and 
one-half to eight and one-half inches), such contraction may be ex- 
cluded. If we find all these external measurements to be normal both 
as to length and relation, then we may safely conclude that the pelvis 
also is normal, and no further examination is required. 

For the purpose of making these measurements, Baudelocque's 
compas d'epaisseur can be used (Fig. 148), or Dr. Lazarewitch's elegant 

Fig. 148. 




Pelvimeter, 

universal pelvimeter, which can be adopted also for internal pelvim- 
etry ; but, in the absence of these special contrivances, an ordinary 
pair of callipers, such as are used by carpenters, can be made to answer 
the desired object. 

These external measurements must be corroborated, when abnormal, 
by internal, chiefly of the antero-posterior diameter, by which alone 



410 



LABOR, 



we can estimate the amount of the deformity. We endeavor to find, 
in the first place, the length of the inclined conjugate, between the 
lower edge of the symphysis pubis and the promontory of the sacrum, 
which averages about half an inch more than the true conjugate. This 
is best done by placing the patient on her back, with the hips well 
raised. The index and middle fingers of the right hand are then in- 
troduced into the vagina, and the perineum is pressed steadily back- 
ward, so as to overcome the resistance it offers. The tip of the middle 
finger is passed steadily upward until it reaches the promontory of the 
sacrum, which is recognized by the breadth of the cartilage between it 
and the last lumbar vertebra. Care must be taken not to mistake the 
junction between the first and second lumbar vertebrae, occasionally 

Fig. 149. 




Greenhalgh's pelvimeter. 

unduly prominent, for the true promontory. If the tip of the finger 
can reach the promontory of the sacrum, the radial side of the hand is 
raised so as to touch the lower edge of the pubes. A mark is made 
with the nail of the index of the left hand on that part of the index 
finger of the right hand which rests under the symphysis, and then the 
distance from this to the tip of the finger, less one-half to three-quarters 
of an inch, may be taken to indicate the measurement of the true con- 
jugate of the brim. Various pelvimeters have been devised to make 
the same measurements, such as Lumley Earle's, Lazarewitch's, which 
is similar in principle, and Van Huevel's ; the best and simplest, I 
think, is that invented by Dr. Greenhalgh (Fig. 149). It consists 
of a movable rod, attached to a flexible band of metal which passes 
around the palm of the examining hand. At the distal end of the rod 
is a curved portion, which passes over the radial edge of the index 
finger. The examination is made in the usual way, and when the 



DEFORMITIES OF THE PELVIS. 411 

point of the finger is resting on the promontory of the sacrum, the rod 
is withdrawn until it is arrested by the posterior surface of the sym- 
physis, the exact measurement of the inclined conjugate being then 

read off the scale. 

It is to he' remembered that this procedure is useless in the slighter 
degrees of contraction, in which the promontory of the sacrum cannot 
be easily reached. Dr. Ramsbotham proposed to measure the conju- 
gate by spreading out the index and middle fingers internally, the tip 
of one resting on the promontory, the other behind the symphysis 
pubis ; and then withdrawing them, in the same position, and meas- 
uring the distance between them. This manoeuvre I believe to be 
impracticable. 

Whenever, in actual labor, we wish to ascertain the condition of 
the pelvis accurately, the patient should be anaesthetized, and the 
whole hand introduced into the vagina (which could not otherwise be 
done without causing great pain), and the proportions of the pelvis, 
and the relations of the head to it, thoroughly explored ; and, if what 
has been said as to the mechanism of delivery in these cases be borne 
in mind, this may aid us in determining the kind of deformity exist- 
ing. In this way contractions about the outlet of the pelvis can also 
be pretty generally made out. 

The obliquely contracted pelvis cannot be determined by any of 
these methods, but certain external measurements, as Naegele has 
pointed out, will readily enable us to recognize its existence. It will 
be found that measurements which in the healthy pelvis ought to be 
equal are unequal in the obliquely distorted pelvis. The points of 
measurement are chiefly: 1. From the tuberosity of the ischium on 
one side to the posterior superior spine of the ilium on the other. 2. 
From the anterior superior iliac spine on the one side to the posterior 
superior on the opposite. 3. From the trochanter major of one side 
to the posterior superior iliac spine on the other. 4. From the lower 
edge of the symphysis pubis to the posterior superior iliac spine on 
either side. 5. From the spinous process of the last lumbar vertebra 
to the anterior superior spine of the ilium on either side. 

If these measurements differ from each other by half an inch to an 
inch, the existence of an obliquely deformed pelvis may be safely 
diagnosed. The diagnosis can be corroborated by placing the patient 
in the erect position, and letting fall tw r o plumb-lines, one from the 
spines of the sacrum, the other from the symphysis pubis. In a 
healthy pelvis these wall fall in the same plane, but in the oblique 
pelvis the anterior line will deviate considerably toward the unaffected 
side. 

Treatment. — The proper management of labor in contracted pelvis 
is, even up to this time, one of the most vexed questions in midwifery, 
notwithstanding the immense amount of discussion to which it has 
given rise ; and the varying opinions of accoucheurs of equal experi- 
ence afford a strong proof of the difficulties surrounding the subject. 
This remark applies, of course, only to the lesser degree of deformity, 
in which the birth of a living child is not hopeless. When the antero- 
posterior diameter of the brim measures from two and three-quarters 



412 LABOR. 

to three inches, it is universally admitted that the destruction of the 
child is inevitable, unless the pelvis be so small as to necessitate the 
performance of the Csesarean section. But when it is between three 
inches and the normal measurement, the comparative merits of the 
forceps, turning, and the induction of premature labor form a fruitful 
theme for discussion. With one class of accoucheurs the forceps is 
chiefly advocated, and turning admitted as an occasional resource when 
it has failed; and this, indeed, speaking broadly, may be said to 
have been the general view held in England. More recently we find 
German authorities of eminence, such as Schroeder and Spiegelberg, 
giving turning the chief place, and condemning the forceps altogether 
in contracted pelves, or at least restricting its use within very narrow 
limits. More strangely still we find, of late, that the induction of 
premature labor, on the origination and extension of which British 
accoucheurs have always prided themselves, is placed without the pale, 
and spoken of as injurious and useless in reference to pelvic deformi- 
ties. To see our way clearly amongst so many conflicting opinions is 
by no means an easy task, and perhaps we may best aid in its accom- 
plishment by considering separately the three operations in so far as 
they bear on this subject, and pointing out briefly what can be said 
for and against each of them. 

The Forceps. — In England and in France it is pretty generally 
admitted that in the slighter degrees of contraction the most reliable 
means of aiding the patient is by the forceps. It should be remem- 
bered that the operation, under such circumstances, is always much 
more serious than in ordinary labors simply delayed from uterine 
inertia, when there is ample room, and the head is in the cavity of 
the pelvis ; for the blades have to be passed up very high, often when 
the head is more or less movable above the brim, and much more 
traction is likely to be required. For these reasons artificial assist- 
ance, when pelvic deformity is suspected, is not to be lightly or hur- 
riedly resorted to. Nor, fortunately, is it always necessary, for if the 
pains be sufficiently strong, and the contraction not too great to pre- 
vent the head engaging at all, after a lapse of time it will become so 
moulded in the brim as to pass even a considerable obstruction. In 
all cases, therefore, sufficient time must be given for this ; and if no 
suspicious symptoms exist on the part of the mother — no elevation of 
temperature, dryness of the vagina, rapid pulse, and the like, and the 
foetal heart sounds continue to be normal — labor may be allowed to 
go on for some hours after the rupture of the membranes, so as to give 
Nature a chance of completing the delivery. When this seems hope- 
less, the intervention of art is called for. 

The forceps is generally considered to be applicable in all degrees 
of contraction, from the standard measurement down to about three 
and a quarter inches in the conjugate of the brim. There can be no 
doubt that in such cases traction with the forceps often enables us to 
effect delivery, when the natural efforts have proved insufficient, and 
holds out a very fair hope of saving the child. Out of seventeen 
cases in which the high forceps operation was resorted to for pelvic 
deformity, reported by Stanesco, in thirteen living children were born. 



DEFORMITIES OF THE PELVIS. 413 

If the Length of the labor, and the Long-continued compression to 
which the child has been subjected, be borne in mind, this result must 
be considered very favorable. 

What are the objections which have been brought against the opera- 
tion? These have been principally made bv Schrocder and other 
German writers. They are, chiefly, the difficulty of passing the in- 
strument ; the risk of injuring the maternal structures; and the sup- 
position that, as the blades must seize the head by the forehead and 
occiput, their compressive action will diminish its longitudinal and 
increase its transverse diameter (which is opposed to the contracted 
part of the brim), and so enlarge the head just where it ought to be 
smallest. There is little doubt that these writers much exaggerate 
the compressive power of the forceps. Certainly, Avith those generally 
used in this country, any disadvantage likely to accrue from this is 
more than counterbalanced by the traction on the head ; and the fact 
that minor degrees of obstruction can be thus overcome, with safety 
both to the mother and child, is abundantly proved by the numberless 
<?ases in which the forceps has been used. 

It is very likely that the forceps does not act equally well in all 
cases. When the head is loose above the brim ; when the contraction 
is chiefly limited to the antero-posterior diameter, and there is abun- 
dance of room at the sides of the pelvis for the occiput to occupy after 
version ; and when, as is usual in these cases, the anterior fontanelle 
is depressed and the head lies transversely across the brim, turning is 
certainly the safer operation for the mother, and the easier performed. 
When, ou the other hand, the head has engaged in the brim, and has 
become more or less impacted, it is obvious that version could not be 
performed without pushing it back, which may be neither easy nor 
safe. Iu the generally contracted pelvis, in which the head enters in 
an exaggerated state of flexion and lies obliquely, the posterior 
fontanelle being much depressed, the forceps is more suitable. 

Mechanical Advantage of Turning- in Certain Cases. — The 
special reasons why version sometimes succeeds when the forceps fails, 
or why it may be elected from the first as a matter of choice, have 
been by no one better pointed out than by Sir James Simpson. 
Although the operation was performed by many of the older obstetri- 
cians, its revival iu modern times, and the clear enunciation of its 
principles, can undoubtedly be traced to his writings. He points out 
that the head of the child is shaped like a cone, its narrowest portion 
the base of the cranium (Fig. 150, b 6), measuring, on an average, from 
one-half to three-quarters of an inch less than the broadest portion 
(Fig. 150. a a), viz., the bi-parietal diameter. In ordinary head pres- 
entations the latter part of the head has to pass first ; but if the feet 
are brought down, the narrow apex of the cranial cone is brought first 
into apposition with the contracted brim, and can be more easily drawn 
through than the broader base can be pushed through by the uterine 
contractions. Nor is this the only advantage, for, after turning, the 
narrower bi-temporal diameter (Fig. 151, b b) — which measures, on an 
average, half an inch less than the bi-parietal (Fig. 151, a a) — is brought 
iuto contact with the contracted conjugate, while the broader bi-parietal 



414 



LABOR. 



lies in the comparatively wide space at the side of the pelvis (Fig. 152). 
These mechanical considerations are sufficiently obvious, and fully 
explain the success which has often attended the performance of the 
operation. 



Fig. 150. 



Fig. 151. 





Section of foetal cranium, showing 
its conical form. 



Showing the greater breadth of the 
bi-parietal diameter of the foetal 
cranium. (After Simpson.) 



Fig. 152. 




Showing the greater space for the bi-parietal diameter at the side of the pelvis in certain 
cases of deformity. (After Simpson.) 

It is generally admitted that it may be possible, for the reasons j ust 
mentioned, to deliver a living child by turning through a pelvis con- 
tracted beyond the point which would permit of a living child being 
extracted by the forceps. Many obstetricians believe that it is possible 
to deliver a living child by turning in a pelvis contracted even to the 
extent of two and three-quarters inches in the conjugate diameter. 
Barnes maintains that, although an unusually compressible head may 
be drawn through a pelvis contracted to three inches, the chance of 
the child being born alive under such circumstances must necessarily 
be small, and that from three and a quarter inches to the normal size 
must be taken as the proper limits of the operation. 

That delivery is often possible by turning, after the forceps and the 
natural powers have failed, and when no other resource is left but 
the destruction of the child, must, I think, be admitted by all ; for the 
records of obstetrics are full of such cases. To take one example 
only, Dr. Braxton Hicks 1 records four cases in which the forceps was 



i Guy's Hospital Reports, 1869-70, vol. xv. 3d ser. p. 501. 



DEFORMITIES OF THE PELVIS. 415 

tried unsuccessfully, in all of which version was used, three of the 
children being born alive. Here arc the lives of three children rescued 
from destruction, within a short period, in the practice of one man ; 
and a fact like this would of itself be ample justification of tin 1 attempt 
to deliver by turning, when the child was known to be alive, and 
other means had tailed. The possibility that craniotomy may still be 
required is no argument against the operation ; for although perfora- 
tion of the after-coming head is certainly not so easy as perforation of 
a presenting head, it is not so much more difficult as to justify the 
neglect of an experiment by which it may possibly be altogether 
avoided. 

The original choice of turning is a more difficult question to decide. 
The most generally received opinion in the present day among scientific 
obstetricians is that in the simply flattened pelvis, with an antero- 
posterior diameter of not less than two and three-quarters inches, turn- 
ing is the preferable operation. [*] In every case of doubt it is desirable 
thoroughly to anaesthetize the patient and make a careful examination 
with the whole hand in the vagina. If we find the sagittal suture 
lying transversely, one parietal bone on a lower line than the other, 
and if both fontanelles are easily within reach, and some space exists 
at the sides of the pelvis beside the forehead and occiput, then turning 
is the procedure most likely to succeed, and the descent of the head 
after version can be very materially assisted by strong pressure applied 
from above by an assistant, as has been well pointed out by Goodell. 2 
If, on the other hand, the anterior fontanelle is high up, and out of 
reach, the head being distinctly flexed, we have to do with a generally 
contracted pelvis, and the forceps is the preferable operation. 

AVhen the contraction is below three inches in the conjugate, or 
when the forceps or turning has failed, no resource is left but the 
destruction of the foetus, or the Caesarean section [or svmphvseotomv. 
—Ed.]. 

The Induction of Premature Labor. — The induction of premature 
labor as a means of avoiding the risk of delivery at term, and of 
possibly saving the life of the child, must now be studied. The estab- 
lished rule in England is, that in all cases of pelvic deformity the 
existence of which has been ascertained either by the experience of 
former labors or by accurate examination of the pelvis, labor should 
be induced previous to the full period, so that the smaller and more 
compressible head of the premature foetus may pass where that of the 
foetus at term could not. The gain is a double one, partly the lessened 
risk to the mother, and partly the chance of saving the child's life. 

The practice is so thoroughly recognized as a conservative and 
judicious one that it might be deemed unnecessary to argue in its 
favor, were it not that some eminent authorities have of late years 
tried to show that it is better and safer to the mother to leave the 
labor to come on at term ; and that the risk to the child is so great in 
artificially induced labor as to lead to the conclusion that the opera - 

[ l At two and three-quarters c.v., symphyseotomy avails to deliver a living foetus, and is 
becoming a favorite operation in our country.— Ed.] 
2 Amer. Journ. of Obstet., 1S75-76, vol. viii. p. 193. 



416 LABOR. 

tion should be altogether abandoned, except, perhaps, in the extreme 
distortion in which the Csesarean section might otherwise be necessary. 
Prominent amongst those who hold these views are Spiegelberg and 
Litzmann, and they have been supported, in a modified form, by 
Matthews Duncan. Spiegelberg 1 tries to show, by a collection of 
cases from various sources, that the results of induced labor in con- 
tracted pelves are much more unfavorable than when the cases are left 
to Nature ; that in the latter the mortality of the mothers is 6.6 per 
cent., and of the children 28.7 per cent., whereas in the former the 
maternal deaths are 15 per cent, and the infantile 66.9 per cent. 
Litzmann 2 arrives at not very dissimilar results — namely, 6.9 per cent, 
of the mothers and 20.3 per cent, of the children in contracted pelvis 
at term, and 14.7 per cent, of the mothers and 55.8 per cent, of the 
children, in artificially induced premature labor. 

If these statistics were reliable, inasmuch as they show a very 
decided risk to the mother, there might be great force in the argument 
that it would be better to leave the cases to run the chance of delivery 
at term. It is, however, very questionable whether they can be taken, 
in themselves, as being sufficient to settle the question. The fallacy 
of determining such points by a mass of heterogeneous cases, collected 
together without a careful sifting of their histories, has over and over 
again been pointed out ; and it would be easy enough to meet them by 
an equal catalogue of cases in which the maternal mortality is almost 
nil. The results of the practice of many authorities are given in 
Churchill's work, where we find, for example, that out of forty-six 
cases of Merriman's, not one proved fatal. The same fortunate result 
happened in sixty-two cases of Bamsbotham's. His conclusion is 
that " there is undoubtedly some risk incurred by the mother, but not 
more than by accidental premature labor," and this conclusion, as 
regards the mother, is that which has long ago been arrived at by the 
majority of British obstetricians, who undoubtedly have more expe- 
rience of the operation than those of any other nation. With regard 
to the child, even if the German statistics be taken as reliable, they 
would hardly be accepted as contra-indicating the operation, inasmuch 
as it is intended to save the mother from the dangers of the more 
serious labor at term, and, in many cases, to give at least a chance to 
the child, whose life would otherwise be certainly sacrificed. The 
result, moreover, must depend to a great extent on the method of oper- 
ation adopted, for many of the plans of inducing labor recommended 
are certainly, in themselves, not devoid of danger both to the mother 
and the child. It may, I think, be admitted, as Duncan contends, 
that the operation has been more often performed than is absolutely 
necessary, and that the higher degrees of pelvic contraction are much 
more uncommon than has been supposed to be the case. That is a 
very valid reason for insisting on a careful and accurate diagnosis, but 
not for rejecting an operation which has so long been an established 
and favorite resource. 

When the induction of labor has been determined on, the precise 

1 Arch. f. Gyn., 1870, Bd. i. S. 1. " Ueber den Werth der kiinstlichen Friihgeburt. 

2 Arch. f. Gyn., 1873, Bd. ii. S. 169. 



DEFORMITIES OF THE PELVIS. 417 

period at which it should be resorted to becomes a question for anxious 
consideration, since the longer it is delayed the greater, of course, are 
the dangers for the child. Many tables have been constructed to guide 
us on this point, which are not, on the whole, of so much service as 
they might appear to be, on account of the difficulty of determining 
with minute accuracy the amount of contraction. The following, 
however, which is drawn up by Kiwisch, may serve for a guide in 
settling this question : 

Inches. Lines. 

When the sacro-pubic diameter is 2 and 6 or 7 induce labor at 30th week. 

2 " s " 9 " " 31st 

2 " 10 " 11 " " 32d 

3 " — " " 33d 
3 " 1 " " 33d 
3 " 2 or 3 " " 34th 
3 " 4 " 5 " " 35th 

" " 3 " 5 " 6 " " 36th 

In cases of moderate deformity, when labor pains have been induced, 
the further progress of the case may be left to Nature : but in more 
marked cases, as in those below three inches, it will often be found 
necessary to assist delivery by turning or by the forceps, the former 
being here specially useful, on account of the extreme pliability of the 
head, and the facility with which it may be drawn through the con- 
tracted brim. By thus combining the two operations it may be quite 
possible to secure the birth of a living child even in pelves very con- 
siderably deformed. 

Production of Abortion in Extreme Deformity. — When the 
contraction is so great as to necessitate the induction of the labor before 
the sixth month, or, in other words, before the child has reached a 
viable age, it would be preferable to resort to a very early production 
of abortion. The operation is then indicated, not for the sake of the 
child, but to save the mother from the deadly risk to which she would 
otherwise be subjected. As in these cases the mother alone is con- 
cerned, the operation should be performed as soon as we have posi- 
tively determined the existence of pregnancy. No object can be gained 
by waiting until the development of the child is advanced to any 
extent, and the less the foetus is developed, the less will be the pain 
and the risk the mother has to undergo. There is no amount of de- 
formity, however great, in which we could not succeed in bringing on 
miscarriage by some of the numerous means at our disposal ; and, in 
spite of Dr. Radford's objections, who maintains that the obstetrician 
is not justified in sacrificing the life of a human being more than once, 
when the mother knows that she cannot give birth to a viable child, 
there are few practitioners who would not deem it their duty to spare 
the mother the terrible dangers of the Caesarean section. 

[We no longer on this side of the Atlantic regard this operation as 
terribly dangerous, neither is it thus feared in Glasgow, Leipzig, Dresden, 
and Vienna, where it has had a mortality of 7 to 10 per cent, in the 
last decade. In our own country, but two women died out of the last 
twenty, covering three years, and but three children were lost, one 
being a six months foetus. One woman that died, did so after twelve 
hours, having been in labor seven days with a placenta prsevia and a 
rigid cervix. — Ed.] 



418 LABOR 



CHAPTEE XIII. 

HEMORRHAGE BEFORE DELIVERY : PLACENTA PREVIA. 

The hemorrhages which are the result of an abnormal situation of 
the placenta, partially or entirely over the internal os uteri, have 
formed a most fruitful theme for discussion. The explanation of the 
abnormal placental site, the sources of the blood and the causes of its 
escape, the means adopted by Xature for its arrest, and the proper 
treatment, have, each and all of them, been the subject of endless con- 
troversies, which are not yet by any means settled. It must be ad- 
mitted, too, that the extreme importance of the subject amply justifies 
the attention which has been paid to it ; for there is no obstetric 
complication more apt to produce sudden and alarming effects, and 
none requiring more prompt and scientific treatment. 

Definition. — By placenta previa we mean the insertion of the pla- 
centa at the lower segment of the uterine cavity, so that a portion of 
it is situated, wholly or partially, over the internal os uteri. In the 
former case there is complete or central placental presentation, in the 
latter an incomplete or marginal presentation. 

Causes. — The causes of this abnormal placental site are not fully 
understood. It was supposed by Tyler Smith to depend on the ovule 
not having been impregnated until it had reached the lower part of the 
uterine cavity. Cazeaux suggests that the uterine mucous membrane 
is less swollen and turgid than when impregnation occurs at the more 
ordinary place, and that, therefore, it offers less obstruction to the 
descent of the ovule to the lower part of the uterine cavity. An 
abnormal size, or unusual shape, of the uterine cavity may also favor 
the descent of the impregnated ovule ; the former probably explains 
the fact that placenta previa more generally occurs in women who 
have already borne children. Muller believes that it results from 
uterine contractions occurring shortly after conception, which force the 
ovum down to the lower part of the uterine cavity. These are merely 
interesting speculations having no practical value, the fact being un- 
doubted that, in a not inconsiderable number of cases — estimated by 
Johnson and Sinclair as 1 out of 573 — the placenta is grafted partially 
or entirely over the uterine orifice, although it is now generally 
admitted that the placenta is never attached to any portion of the 
cervix itself. 

History. — Placenta prsevia was not unknown to the older writers, 
who believed that the placenta had originally been situated at the 
fundus, from which it had accidentally fallen to the lower part of the 
uterus. Portal, Levret, Roederer, and especially the British author 
Higby, were among those whose observations tended to improve the 



HEMORRHAGE BEFORE DELIVERY. 419 

state of obstetrical knowledge as to its peal nature. To Rigby we owe 
the term unavoidable hemorrhage^ as a synonym for placenta previa, 
and as distinguishing hemorrhage from this source from that resulting 

from separation of the placenta at its more usual position, termed by 
him, in contra-distinction, accidental hemorrhage. These names, adopted 
by most writers on the subject, are obviously misleading, as they assume 
an essential distinction in the etiology of the hemorrhage in the two 

classes of eases, which is not always warranted. 

It is of the utmost importance to a right understanding of the nature 
and treatment of placenta praevia that we should fully understand the 
source of the hemorrhage and the manner of its production ; but we 
shall be able to discuss this subject better after a description of the 
symptoms. 

Symptoms. — Although the placenta must occupy its unusual site 
from the earliest period of its formation, it rarely gives rise to appre- 
ciable symptoms before the last three months of utero-gestation. It is 
far from unlikely, however, that such an abnormal situation of the 
placenta may produce abortion in the earlier mouths, the site of its 
attachment passing unobserved. 

The earliest symptom which causes suspicion is the sudden occur- 
rence of hemorrhage, without any appreciable cause. The amount of 
blood lost varies considerably. In some cases the first hemorrhage is 
comparatively slight, and is soon spontaneously arrested ; but, if the 
case be left to itself, the flow after a lapse of time — it may be a few 
days, or it may be weeks — again commences in the same unexpected 
way, and each successive hemorrhage is more profuse. The losses 
show themselves at different periods. They rarely begin before the 
end of the sixth month, more often nearer the full period, and some- 
times not until labor has actually commenced. The hemorrhage is 
said, but this is doubtful, to often coincide with what would have been 
a menstrual period ; possibly on account of the physiological conges- 
tion of the uterine organs then present. Should the first loss not show 
itself until at or near the full time, it may be tremendous, and a few 
moments may suffice to place the patient's life in jeopardy. Indeed, it 
may be safely accepted as an axiom, that once hemorrhage has occurred, 
the patient is never safe ; for excessive losses may occur at any moment 
without warning, and when assistance is not at hand. It often happens 
that premature labor comes on after one or more hemorrhages. 

In any case of placenta prsevia, when labor has commenced, whether 
premature or at the full time, the hemorrhage may become excessive, 
and with each pain fresh portions of placenta may be detached and 
fresh vessels torn and left open. Under these circumstances the blood 
often escapes in greater quantity with each successive pain, and 
diminishes in the interval. This has long been looked upon as a 
diagnostic mark by which we can distinguish between the so-called 
" unavoidable " and " accidental " hemorrhage ; in the latter the flow 
being arrested during the pains. The distinction, however, is altogether 
fallacious. The tendency of uterine contraction in placenta praevia, as 
in all other forms of uterine hemorrhage, is to constrict the vessels 
from which the blood escapes, and so to lessen the flow. The appar- 



420 LABOK. 

ently increased flow during the pains depends on the pains forcing out 
blood which has already escaped from the vessels. In one way, up to 
a certain point, the pains do favor hemorrhage, by detaching fresh por- 
tions of placenta ; but the actual loss takes place chiefly during the 
intervals, and not during the continuance of contraction. 

On vaginal examination, if the os be sufficiently open to admit the 
finger, which it generally is on account of the relaxation produced by 
the loss of blood, we shall almost always be able to feel some portion 
of presenting placenta. If it be a central implantation, we shall find 
the aperture of the cervix entirely covered by a thick, boggy mass 
which is to be distinguished from a coagulum by its consistence, and 
by its not breaking down under the pressure of the finger. Through 
the placental mass we may feel the presenting part of the foetus ; but 
not as distinctly as when there is no intervening substance. In partial 
placental presentations the bag of membranes, and above it the head 
or other presentation, will be found to occupy a part of the circle of 
the os, the rest being covered by the edge of the placenta. In marginal 
presentations we may only be able to make out the thickened edge of 
the afterbirth, projecting at the rim of the os. If the cervix be high, 
and the gestation not advanced to term, these points may not be easy 
to make out, on account of the difficulty of reaching the cervix ; and, 
as accurate diagnosis is of the utmost importance, it is proper to intro- 
duce two fingers, or even the whole hand, so as thoroughly to explore 
the condition of the parts. The lower portion of the uterine ovoid 
may be observed to be more than usually thick and fleshy; and 
Gendrin has pointed out that ballottement cannot be made out. The 
accuracy of our diagnosis may be confirmed, in doubtful cases, by 
finding that the placental bruit is heard over the lower part of the 
uterine tumor. 

Dr. Wallace 1 has suggested that vaginal auscultation maybe service- 
able in diagnosis, and states that, by means of a curved wooden stetho- 
scope, the placental bruit may be heard with startling distinctness. 
This is, however, a manoeuvre that can hardly be generallv carried out 
in actual practice. 

It is now generally admitted by authorities that the immediate 
source of the hemorrhage is the lacerated utero-placental vessels. Only 
a few years ago Sir James Y. Simpson advocated, with his usual energy, 
the theory, sustained by his predecessor, Dr. Hamilton, that the chief, 
if not the only, source of hemorrhage was the detached portion of the 
placenta itself. He argued that the blood flowed from the portion of 
the placenta which was still adherent into that which was separated, 
and escaped from the surface of the latter ; and on this supposition he 
based his practice of entirely separating the placenta, having observed 
that, in many cases in which the afterbirth had been expelled before 
the child, the hemorrhage had ceased. The fact of the cessation of the 
hemorrhage, when this occurs, is not doubted ; but Simpson's explana- 
tion is contested by most modern writers, prominent among whom is 
Barnes, who has devoted much study to the elucidation of the subject. 

i Edin. Med. Journ., vol. 1872-73, p. 427 



HEMORRHAGE BEFORE DELIVERY. 12] 

He points out thai the stoppage of the hemorrhage is nol due to the 
separation of the placenta, but to the preceding or accompanying con- 
traction of the uterus, which seals up the bleeding vessels, jusl as it 
does iii other forms of hemorrhage. The Bite of tin- loss was actually 
demonstrated by the late Dr. Mackenzie in a series of experiments, in 
which ho partially detached the placenta in pregnant bitches, and found 
that the blood flowed from the walls of the uterus, and not from the 
detached surface of the placenta. The arrangement of the large 
venous sinuses, opening as they do on the uterine mucous membrane, 
favors the escape of blood when they are torn across; and it is from 
them, possibly to some extent also from the uterine arteries, that the 
blood comes, just as in post-partnm hemorrhage, when the whole, 
instead of a part, of the placental site is bared. 

Various explanations have been given of the causes of the hemor- 
rhage. For long it was supposed to depend on the gradual expansion 
of the cervix during the latter months of pregnancy, which separated 
the abnormally placed placenta. It has been seen, however, that this 
shortening of the cervix is apparent only, and that the cervical canal 
is not taken up into the uterine cavity during gestation, or, at all 
events, only during the last week or so. This, therefore, cannot be 
admitted as an explanation of placental separation. Jacqnemier pro- 
posed another theory, which has been adopted by Cazeanx. He 
maintains that during the first six months of ntero-gestation the 
superior portion of the uterus is more especially developed, as shown 
by the pyriform shape of the fundus during the time ; and that, as the 
placenta is usually attached in that situation, and then attains its 
maximum of development, its relations to its attachments are undis- 
turbed. During the last three months of pregnancy, on the contrary, 
the lower segment of the uterus develops more than the upper, while 
the placenta remains nearly stationary in size ; the inevitable result 
being a loss of proportion between the cervix and the placenta, and 
the detachment of the latter. There are various objections which can 
be brought against this theory ; the most important being that there is 
no evidence at all to show that the lower segment of the uterus does 
expand more in proportion than the upper during the latter months of 
pregnancy. Barnes's theory is based on the supposition that the loss 
of relation between the uterus and placenta is caused by excess of 
growth on the part of the placenta itself over that of the cervix, which 
is not adapted for its attachment. The placenta, on this hypothesis, 
grows away from the site of its attachment, and hemorrhage results. 
It will be observed that neither this theory nor that propounded by 
Jaccpiemier is readily reconcilable Avith the fact that hemorrhage fre- 
quently does not begin until labor has commenced at term. Inasmuch 
as the loss of relation between the placenta and its attachments, which 
they both presuppose, must exist in every case of placenta prsevia, 
hemorrhage should always occur during some part of the last three 
months of pregnancy. Matthews Duncan 1 lias recently investigated 
the whole subject at length, and maintains that the hemorrhages are 

i Edin. Med. Journ., vol. 1873-74, pp. aS5, 520; and Brit. Med. Journ., 1*7:], vol. ii. pp. 4'.»'.', 597, 825. 



422 LABOR. 

accidental, not unavoidable, being due to causes precisely similar to 
those which give rise to the occasional hemorrhages when the placenta 
is normally placed. The abnormal situation of the placenta of course 
renders these causes more apt to operate ; but in their action he believes 
them to be precisely similar to those of accidental hemorrhage, properly 
so called. Separation of the placenta from expansion of the cervix lie 
believes to be the cause of hemorrhage after labor has begun, and then 
it may strictly be called unavoidable ; but hemorrhage is comparatively 
seldom so produced during the continuance of pregnancy. " There 
are," says Duncan, " four ways in which this kind of hemorrhage may 
occur : 

"1. By the rupture of a utero-placental vessel at or about the in- 
ternal os uteri. 

"2. By the rupture of a marginal utero-placental sinus within the 
area of spontaneous premature detachment, when the placenta is in- 
serted not centrally or covering the internal os. but with a margin at 
or near the internal os. 

" 3. By partial separation of the placenta from accidental causes. 
such as a jerk or fall. 

" 4. By a partial separation of the placenta, the consecjuenee of 
uterine pains producing a small amount of dilatation of the internal 
os. Such cases may be otherwise described as instances of miscarriage 
commencing, but arrested at a very early stage." 

I see no reason to doubt the possibility of hemorrhage being due, 
in many cases, to the first three causes, and in its production it would 
strictly resemble accidental hemorrhage. The fourth heading refers 
the hemorrhage to partial separation, in consequence of commencing 
dilatation of the cervix, but it explains the dilatation by the suppo- 
sition of commencing miscarriage. This latter hypothesis seems to be 
as needless as those which presuppose a want of relation between the 
placenta and its attachments. AVe know that, quite independently of 
commencing miscarriage, uterine contractions are constantly occurring 
during the continuance of pregnancy. There is no reason to suppose 
that these contractions do not affect the cervical as well as the fundal 
portions of the uterus : and in cases in which the placenta is situated 
partially or entirely over the os, one or more stronger contractions 
than usual may, at any moment, produce laceration of the placental 
attachments in that neighborhood. 

Pathological Changes in the Placenta. — A careful examination 
of the placenta may show pathological changes at the site of separation, 
such as have been described by Gendrin, Simpson, and other writers. 
They probably consist of thromboses in the placental cotyledons, and 
effused blood-clots, variously altered and decolorized, according to the 
lapse of time since separation took place. Changes occur in the por- 
tion of the placenta overlying the os uteri, whether separation has 
occurred or not. There may be atrophy of the placental structure 
in this situation, as well as changes of form, such as complete or 
partial separation into two lobes, the junction of which overlies the 
os uteri. 1 

1 Sinelius : Arch. sren. de Med.. 1861. torn. ii. 



HEMORRHAGE BEFORE DELIVERY. 423 

The history of delivery, if left to Nature, is specially worthy of 
study, as guiding to proper rules of treatment. It sometimes happens, 
when the pains are very strong and the delivery rapid, thai labor is 
completed without any hemorrhage of consequence. "Although," 
says Cazeaux, "hemorrhage is usually considered to be inevitable 
under such circumstances, yet it may not appear even during the 
labor; and the dilatation of the OS uteri may he effected without the 
loss of a drop of blood." Again, Simpson conclusively showed that, 
when the placenta was expelled before the birth of the child, all 
hemorrhage ceased. 

Barnes's theory of placenta prsevia, which has been pretty generally 
adopted, explains satisfactorily both these classes of eases. 

He describes the uterine cavity as divisible into three zones or 
regions. When the placenta is situated in the upper or middle of 
these zones, no separation or hemorrhage need occur during labor. 
When, however, it is situated partially or entirely in the lower or 
cervical zone, the expansion of the cervix during labor must produce 
more or less separation and consequent loss of blood. As soon as the 
previous portion of the placenta is sufficiently separated, provided 
contraction of the uterine tissue be present to seal up the mouths of 
the vessels, hemorrhage no longer takes place. The placenta may not 
be entirely detached, but no further hemorrhage occurs, in consequence 
of the remaining portion being engrafted on the uterus beyond the 
region of unsafe attachment. 

In the former, then, of these classes of cases, the absence of hemor- 
rhage is explained on this theory, by the pains being sufficiently rapid 
and strong to complete the separation of the placental attachment 
from the lower cervical zone before flooding had taken place ; in the 
latter it ceases, not necessarily because the entire placenta is expelled, 
but because of its detachment from the area of dangerous im- 
plantation. 

The amount of cervical expansion required for this purpose varies 
in different cases. Dr. Duncan 1 estimates the limit of the spontaneous 
detaching area to be a circle of four and a half inches diameter, and 
that, after the cervix has expanded to that extent, no further separa- 
tion or hemorrhage takes place. To admit of the passage of a full- 
sized head, Barnes estimates that expansion to about a circle of six 
inches diameter is necessary ; on the other hand, he has sometimes 
observed " that the hemorrhage has completely stopped when the os 
uteri opened to the size of the rim of a wineglass, or even less." 

It will be seen then that in this, as in every other form of puerperal 
hemorrhage, the tendency of uterine contraction is to check the hem- 
orrhage; and that, provided the pains are sufficiently energetic, Nature 
may be capable of stopping the flooding without artificial aid. It is 
but rarely, however, that she can be trusted for this purpose ; and we 
shall presently see that these theoretical views have an important 
practical bearing on the subject of treatment. 

Prognosis. — The prognosis to both the mother and child is certainly 

i Obst. Trans., 1874, vol. xv. p. 189. 



424 LABOR. 

grave in all cases of placenta prsevia. Read, in his treatise on placenta 
praevia, estimates the maternal mortality, from the statistics of a large 
number of cases, as one in four and a half cases, and Churchill as one 
in three. This is unquestionably too high an estimate, and based on 
statistics the accuracy of which cannot be relied on. The mortality 
will, of course, greatly depend on the treatment adopted. Doubtless, 
if cases were left to Nature, the result would be quite as unfavorable 
as Read supposes. But if properly managed, much more successful 
results may safely be anticipated. Out of sixty-seven cases recorded 
by Barnes, the deaths were six,' or one in eight and a half. Under 
any circumstances the risks to the mother are very great. Churchill 
estimates that more than half the children are lost. The reasons for 
the great danger to the child are very obvious, subjected as it is to the 
risk of asphyxia from the loss of the maternal blood, and from its 
oxygenation being carried on during labor by a placenta which is only 
partially attached ; many children also perish from prematurity, or 
from malpresentation. 

Treatment. — Whenever, in the latter months of pregnancy, a sudden 
hemorrhage occurs, the possibility of placenta previa will naturally 
suggest itself; and by a careful vaginal examination, which under 
such circumstances should always be insisted on, the existence of this 
complication will generally be readily ascertained. It is seldom that 
the os is not sufficiently dilated to enable us to satisfy ourselves whether 
the placenta is presenting. 

The first question that will arise is, Are we justified in temporizing, 
using means to check the hemorrhage, and allowing the pregnancy to 
continue ? This is the course which has generally been recommended 
in works on midwifery. We are told to place the patient on a hard 
mattress, not to heat or overburden her with clothes, to keep her abso- 
lutely at rest, to have the room cool and well aired, to apply cold 
cloths to the vulva and lower part of the abdomen, to administer cold 
and acidulated drinks in abundance, and to prescribe acetate of lead 
and opium, or gallic acid, on account of their supposed haemostatic 
effect. Of late years the judiciousness of these recommendations has 
been strongly contested. Not long ago an interesting discussion took 
place at the Obstetrical Society of London, 1 on a paper in which Dr. 
Greenhalgh advised the immediate induction of labor in all cases of 
placenta prsevia. No less than six metropolitan teachers of midwifery 
took part in it, and, although they differed in details, they all agreed 
as to the unadvisability of allowing pregnancy to progress when the 
existence of placenta prsevia had been distinctly ascertained. The 
reasons for this course are obvious and unanswerable. The labor, 
indeed, very often comes on of its own accord ; but should it not do 
so the patient's life must be considered to be always in jeopardy until 
the case is terminated, for no one can be sure that most dangerous, or 
even fatal, flooding may not at any moment come on ; and the nearer 
to term the patient is, the greater the risk to which she is subjected. 
Nor is the safety of the child likely to be increased by delay. Pro- 

i Obst. Trans., 1865, vol. vi. p. 188. 



HEMORRHAGE BEFORE DELIVERY. 425 

vided it lias arrived al a viable age, the chances of its being born alive 
may be said to be greater if pregnancy be terminated at once, than if 
repeated floodings occur. I think, therefore, thai it may hie safely 
laid down as an axiom, thai do attempt should be made to prevent the 
termination of pregnancy, bul thai our treatment should rather con- 
template its conclusion as soon as possible. An exception may, how- 
ever, be made to this rule when the hemorrhage occurs for the first 
time before the seventh month of utero-gestation. The chances of 
the child surviving would then be very small, and if the hemorrhage 
be not alarming, as at that early period is likely to be the case, the 
measures indicated above may be employed, in the hope of carrying 
on the pregnancy until there is a prospect of the patient being de- 
livered of a living child. But little benefit is likely to accrue from 
astringent drugs. Perfect rest in bed is more likely to be beneficial 
than anything else. 

"When the period of pregnancy, or the urgency of the ease, deter- 
mines ns to forego any attempt at temporizing, there are various plans 
of treatment to be considered. These are chiefly : 1. Puncture of the 
membranes. 2. Plugging the vagina. 3. Turning. 4. Partial or 
complete separation of the placenta. It will be well to consider in 
detail the relative advantages of, and indications for, each of these. 
It is seldom, however, that we can trust to any one per se ; in most 
eases, two or more are required to be used in combination. 

1. Puncture of the membranes is recommended by Barnes as the 
first measure to be adopted in all eases of placenta praevia sufficient 
to cause anxiety. "It is," he says, "the most generally efficacious 
remedy, and it can always be applied." The primary object gained is 
the increase of uterine contraction by the evacuation of the liquor 
amnii. Although the first effect of this may be to increase the flow 
of blood by further separation of the placenta, the flooding can gen- 
erally be commanded by plugging until the os is sufficiently dilated 
to permit the passage of the child. As a rule, there is no great diffi- 
culty in effecting the puncture, especially if the placental presentation 
be only partial. A quill, or other suitable contrivance, guided by the 
examining finger, is passed through the cervix and pushed through 
the membranes. In complete placenta prsevia it may not be so easy 
to effect the evacuation of the liquor amnii ; and, although many 
authorities advise the penetration of the substance of the placenta 
itself, I am inclined to think that it would be better to abandon the 
attempt, in such cases, and trust to other methods of treatment. 

The objections which have been raised to puncture of the mem- 
branes are chiefly that it interferes with the gradual dilatation of the 
os, and renders the operation of turning much more difficult. The os 
is not, however, so regularly dilated by the bag of membranes in cases 
of placenta praevia as it is in ordinary labors. Moreover, as the cer- 
vical tissues are generally relaxed by the hemorrhage, the dilatation is 
easily effected. Should we desire to dilate the os preparatory to turn- 
ing, we can readily do so by means of fluid dilators. The new dilator 
of Champetier de Kibes will probably be found very useful, since it 
will not only rapidly and effectively dilate the cervix and thus pre- 



426 LABOR, 

pare the way for subsequent turning, but also act as an efficient plug. 
The objections, therefore, are not so weighty as they might have been 
before these artificial dilators were used. I am inclined, for these 
reasons, to agree with the recommendation that puncture of the mem- 
branes should be resorted to in all cases of placenta prsevia. 

2. Plugging of the vagina, or, still better, of the cavity of the 
cervix itself, is especially serviceable in cases in which the os is not 
sufficiently dilated to admit of turning, or of separation of the placenta, 
and in which the hemorrhage still continues after the evacuation of 
the liquor amnii. By means of this contrivance the escape of blood 
is effectually controlled. 

A good way of plugging is to introduce a sponge tent of sufficient 
size into the cervical canal, and to keep it in situ by a vaginal plug ; 
the best material for the latter, and the method of introduction, are 
described under the head of Abortion (p. 262). The sponge tent not 
only controls the hemorrhage more effectually than any other means, 
but is, at the same time, effecting dilatation of the cervix. It cannot 
be left in many hours, on account of the irritation produced and of the 
fetor from accumulating vaginal discharges, and the consequent risk 
of septic absorption. This is by no means slight, and it is now pretty 
generally recognized that the plug should not be used unless other 
means of treatment are inapplicable on account of the want of dilata- 
tion of the os. As long as it is in position, we should carefully 
examine, from time to time, to see that no blood is oozing past it. If 
preferred, a Barnes bag may be used for the same purpose. 

While the plug is in situ other modes of exciting uterine action may 
be very advantageously employed, such as a firm abdominal bandage, 
occasional friction over the uterus, and repeated doses of ergot. The 
last is specially recommended by Dr. Greenhalgh, who used, at the 
same time, a plug formed of an oblong India-rubber ball inflated with 
air and covered with spongio-piline. 

On the removal of the plug we may find that considerable dilatation 
has taken place, perhaps to a sufficient extent to admit of labor being 
safely concluded by the natural efforts. In that case we shall find 
that, although the pains continue, no fresh hemorrhage occurs. Should 
it do so, it will be necessary to adopt further measures. 

3. Turning has long been considered the remedy par excellence in 
placenta prsevia ; and it is of unquestionable value in suitable cases. 
Much harm, however, has been done when it has been practised before 
the os was sufficiently dilated to admit of the passage of the hand, or 
when the patient was so exhausted by previous hemorrhage as to be 
unable to bear the shock of the operation. The records of many fatal 
cases in the practice of those who taught, as did the large majority of 
the older writers, that turning at all risks was essential, conclusively 
prove this assertion. 

It is most likely to prove serviceable when, either at first or after 
the use of the tampon, the os is sufficiently dilated to admit the hand, 
and when the strength of the patient is not much enfeebled. If she 
have a small, feeble, and thready pulse, it is certainly inapplicable, 
unless all other methods of arresting the hemorrhage have failed. 



I 



HEMORRHAGE BEFORE DELIVERY. 127 

Ami, even then, it would be well to attempt to rally the patient from 
her exhausted state by stimulant-, etc., before the operation is com- 
menced. 

Provided the placental presentation be partial, the operation can be 
performed without difficulty in the usual way. In central implanta- 
tion the passage of the hand may give rise to Borne difficulty. Dr. 
Rigby recommends that it should be pushed through the substance of* 
the placenta until it reaches the uterine cavity. It is hardly possible 
to conceive how this could be done without completely detaching the 
placenta, and still less to understand how the foetus could be dragged 
through the aperture thus made. It will be far better to pass the 
hand by the border of the placenta, separating it as we do so ; and, if 
we can ascertain to which side of the cervix it is least attached, that 
should be chosen for the purpose. In all cases in which it is possible, 
turning by the bi-polar method should be preferred. In cases <>f 
placenta prsevia especially it offers many advantages. The operation 
can be soon performed; complete dilatation of the os is not so neces- 
sary ; and it involves less bruising of the cervix, which is likely to be 
specially dangerous. When once a lower extremity has been brought 
within the os, the delivery should not be hurried. The limb of the 
child forms a plug, which effectually prevents all further loss; and 
we may then safely wait until Ave can excite uterine contraction and 
terminate the labor with safety. The results of this method of treating 
placenta prsevia have been excellent. Hoffmeier relates thirty-seven 
cases managed in this way with only one death, and Behni thirty-five 
with none. 1 Fortunately, the relaxation of the uterus, which is so 
often present, facilitates this manner of performing version, and it can 
generally be successfully accomplished. Should the ease be one which 
is otherwise suitable for turning, and the requisite amount of dilata- 
tion of the cervix not be present, the latter can generally be effected 
in the space of an hour or more (while at the same time a further loss 
of blood is effectually prevented) by the use of fluid dilators. 

4. Entire separation of the placenta was originally recommended 
by Simpson in his well-known paper on the subject. The reasons 
which induced him to recommend it have already been stated. It is a 
mistake to suppose, however, as is so often done, that he intended to 
recommend it in all eases alike. This supposition he was always 
careful to deny. He advised it especially — 

1. When the child is dead. 

2. When the child is not yet viable. 

3. When the hemorrhage is great and the os uteri is not vet suffi- 
ciently dilated for safe turning. This was the state in eleven out of 
thirty-nine eases (Lee). 

4. When the pelvic passages are too small for safe and easy turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the licpior amnii fails. 

7. When the uterus is too firmly contracted for turning. 2 

1 Zeitschr. f. Geburt. und Gynafe., 1SS2, Bd. viii. S. 89; 188:3, Bd. ix. S. 373, "Die combinirte 
Wendung bei Placenta Prsevia." 

2 Selected Obst. Works, p. 68. 



428 LABOR. 

These are very much the cases in which all modern accoucheurs 
would exclude the operation of turning ; and it was specially when 
that was unsuitable that Simpson advised extraction of the placenta. 
As his theory of the source of hemorrhage is now almost universally 
disbelieved, so has the practice based on it fallen into disuse, and it 
need not be discussed at length. It is very doubtful whether the 
complete separation and extraction of the placenta was a feasible oper- 
ation ; unquestionably it can be by no means so easy as Simpson's 
writings would lead us to suppose. The introduction of the hand far 
enough to remove the placenta in an exhausted patient would probably 
cause as much shock as the operation of turning itself; and another 
very formidable objection to the procedure is the almost certain death 
of the child, if any time elapse between the separation of the placenta 
and the completion of delivery. The modification of this method, so 
strongly advocated by Barnes, is certainly much easier of application, 
and would appear to answer every purpose that Simpson's operation 
effected. It is impossible to describe it better than in Barnes's own 
words i 1 

" The operation is this: Pass one or two fingers as far as they will 
go through the os uteri, the hand being passed into the vagina if 
necessary ; feeling the placenta, insinuate the finger between it and the 
uterine wall ; sweep the finger round in a circle so as to separate the 
placenta as far as the finger can reach ; if you feel the edge of the 
placenta, where the membranes begin, tear open the membranes care- 
fully, especially if these have not been previously ruptured ; ascertain, 
if you can, what is the presentation of the child before withdrawing 
your hand. Commonly, some amount of retraction of the cervix takes 
place after the operation, and often the hemorrhage ceases" 

It will be seen from what has been said, that no one rule of practice 
can be definitely laid down for all cases of placenta prsevia. Our 
treatment in each individual case must be guided by the particular 
conditions that are present ; and, if only we bear in mind the natural 
history of the hemorrhage, we may confidently expect a favorable 
termination. 

It may be useful, in conclusion, to recapitulate the rules which have 
been laid down for treatment in the form of a series of propositions : 

1. Before the child has reached a viable age, temporize, provided 
the hemorrhage be not excessive, until pregnancy has advanced suffi- 
ciently to afford a reasonable hope of saving the child. For this 
purpose the chief indication is absolute rest in bed, to which other 
accessory means of preventing hemorrhage, such as cold, etc., may be 
added. 

2. In hemorrhage occurring after the seventh month of utero-gesta- 
tion, no attempt should be made to prolong the pregnancy. 

3. In all cases in which it can be easily effected, the membranes 
should be ruptured. By this means uterine contractions are favored 
and the bleeding vessels compressed. 

4. If the hemorrhage be stopped, the case may be left to Nature. 

1 Obstet. Operations, 2d ed., p. 417. 



HEMORRHAGE BEFORE DELIVERY, 429 

It' flooding continue, and the os be not sufficiently dilated to admit of 
the labor being readily terminated by turning, the os and the vagina 
should be carefully plugged, while uterine contractions arc promoted 
by abdominal bandages, uterine compression, and ergot. The plug 
must not be left in beyond a few hours, and careful antisepsis should 

be used. 

5. If, on removal of the plug, the os be sufficiently expanded, and 
the general condition of the patient be good, the labor may be ter- 
minated by turning, the bi-polar method being used if possible, and 

the lower extremity of the child will form a plug until delivery is 
completed. If the os be not open enough, it may be advantageously 
dilated by a fluid dilator bag, which also acts as a plug. 

6. Instead of, or before resorting to, turning, the placenta may bo 
separated around the site of its attachment to the cervix. This prac- 
tice is specially to be preferred when the patient is much exhausted 
and in a condition unfavorable for bearing the shock of turning. 

[Dr. J. Braxton Hicks's bimanual method of turning", as tested 
in Berlin by Drs. Hofmeier, Behm, and Lomer, promises much better 
results than any other method of treatment in cases of placenta praBvia. 
According to Dr. Lomer's report in the Ainer. Journ. of Obstetrics for 
December, 1881, Dr. Hofmeier operated upon 37 eases, and saved 36 
women and 14 children; Dr, Behm, upon 40 cases, all saved, but lost 
31 children; and he himself, with eight other assistants, upon 101 eases, 
saving 94, with 50 children. This gives 8 deaths of women and 105 
of children in 178 cases, or a mortality of 4 J per cent, of the former 
and 60 per cent, of the latter. Dr. Lomer's directions are as follows : 
" Turn by the bimanual method as soon as possible ; pull down the 
leg, and tampon with it and with the breech of the child the ruptured 
vessels of the placenta. Do not extract the child then; let it come by 
itself, or at least only assist its natural expulsion by gentle and rare 
tractions. Do away with the plug as much as possible ; it is a dan- 
gerous thing, for it favors infection and valuable time is lost with its 
application. Do not wait in order to perform turning until the cervix 
and the os are sufficiently dilated to allow the hand to pass. Turn 
as soon as you can pass one or two fingers through the cervix. It is 
unnecessary to force your fingers through the cervix for this. Intro- 
duce the whole hand into the vagina, pass one or two fingers through 
the cervix, rupture the membranes, and turn by Braxton Hicks's bi- 
manual method." . . . "If the placenta is in your way, try to 
rupture the membranes at its margin ; but if this is not feasible, do 
not lose time ; perforate the placenta with your finger; get hold of a 
leg as soon as possible, and bring it down." — Ed.] 



430 LABOR. 



CHAPTEE XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY SITUATED 

PLACENTA. 

Definition. — This is the form of hemorrhage which is generally 
described in obstetric works as accidental, in contradistinction to the 
unavoidable hemorrhage of placenta prsevia. In discussing the latter 
we have seen that the term " accidental" is one that is apt to mislead, 
and that the causation of the hemorrhage in placenta prsevia is, in 
some cases at least, closely allied to that of the variety of hemorrhage 
we are now considering. 

When, from any cause, separation of a normally situated placenta 
occurs before delivery, more or less blood is necessarily effused from 
the ruptured utero-placental vessels, and the subsequent course of the 
case may be twofold : 1. The blood, or at least some part of it, may 
find its way between the membranes and the decidua, and escape from 
the os uteri. This constitutes the typical " accidental " hemorrhage of 
authors. 2. The blood may fail to find a passage externally, and may 
collect internally (see Plate IV.), giving rise to very serious symptoms, 
and even proving fatal, before the true nature of the case is recognized. 
Cases of this kind are by no means so rare as the small amount of 
attention paid to them by authors might lead us to suppose ; and, from 
the obscurity of the symptoms and difficulty of diagnosis, they merit 
special study. Dr. Goodell 1 has collected no less than 106 instances 
in which this complication occurred. 

Causes and Pathology. — -The causes of placental separation may 
be very various. In a large number of cases it has followed an acci- 
dent or exertion (such as slipping down stairs, stretching, lifting heavy 
weights, and the like) which has probably had the effect of lacerating 
some of the placental attachments. At other times it has occurred 
without such appreciable cause, and then it has been referred to some 
change in the uterus, such as a more than usually strong contraction 
producing separation, or some accidental determination of blood causing 
a slight extravasation between the placenta and the uterine wall, the 
irritation of which leads to contraction and further detachment. Causes 
such as these, which are of frequent occurrence, will not produce de- 
tachment except in women otherwise predisposed to it. It generally 
is met with in women who have borne many children, more especially 
in those of weakly constitution and impaired health, and rarely in 
primiparse. Certain constitutional states probably predispose to it, 
such as albuminuria or exaggerated anaemia ; and, still more so, de- 
generations and diseases of the placenta itself. 

i Amer. Journ. of Obstet., 1869-70, vol. ii. p. 281. 



PLATE IV. 



Blood-clot 



Placental site \ 1 



Posterior wall of uterus 



Retro-placental blood-clot j 






Placental site 




Placenta attached 
to wall producing 
inversion 



Anterior wall 
of uterus 



Membranes 



Placenta 



VERTICAL MESIAL SECTION OF UTERUS WITH PLACENTA PARTIALLY ATTACHED- 
from a case of abdominal section for hemorrhage during labor. After Barbour. 



( To face page 430.) 



HEMOKRHAGE BEFORE DELIVERY. 431 

This form of hemorrhage rarely occurs to an alarming extent until 
the later months <){' pregnancy, often not until labor lias commenced. 
The great >i/e of the placental vessels in advanced pregnancy affords 

a reasonable explanation of this fact. 

Symptoms and Diagnosis. — If, after separation of a portion of 
the placenta, the blood finds its way between the membranes and the 
decidua, its escape per vaginam, even although in small amount, at 
once attracts attention, and reveals the nature of the accident. It is 
otherwise when we have to deal with a case of concealed hemorrhage, 
the diagnosis of which is often a matter of difficulty. Then the blood 
probably at first collects between the uterus and placenta. Sometimes 
marginal separation does not occur, and large blood-clots are formed 
in this situation, and retained there. More often the margin of the 
placenta separates, and the blood collects between the membranes and 
the uterine wall, either toward the cervix, where the presenting part 
of the child may prevent its escape, or near the fundus. In the latter 
case especially, the coagula are apt to cause very painful stretching 
and distention of the uterus. The blood may also find its way into 
the amniotic cavity, but more frequently it does not do so ; probably, 
as Goodell has pointed out, because, "should the os uteri be closed, 
the membranes, however delicate, cannot, other things being equal, 
rupture any sooner from the uterine walls, for the sum of the resist- 
ance of the enclosed liquor amnii being equally distributed exactly 
counter-balances the sum of the pressure exerted by the effusion.' 7 
This point is of some practical importance, because, after rupture of 
the membranes, the liquor amnii is frequently found untinged with 
blood, and this might lead us to suppose ourselves mistaken in our 
diagnosis, if this fact were not borne in mind. 

The most prominent symptoms in concealed internal hemorrhage 
are extreme collapse and exhaustion, for which no adequate cause can 
be assigned. These differ from those of ordinary syncope, with which 
they might be confounded, chiefly in their persistence and severity, 
and in the presence of the symptoms attending severe loss of blood, 
such as coldness and pallor of the surface, great restlessness and 
anxiety, rapid and sighing respiration, yawning, feeble, quick, and 
compressible pulse. AVhen there is severe internal, with slight exter- 
nal, hemorrhage, we may be led to a proper diagnosis by observing 
that the constitutional symptoms are much more severe than the 
amount of external hemorrhage would account for. Uterine pain is 
generally present, of a tearing and stretching character, sometimes 
moderate in amount, more often severe, and occasionally amounting to 
intolerable anguish. It is often localized, and, doubtless, depends on 
the distention of the uterus by the retained coagula. If the disten- 
tion be marked, there may be an irregularity in the form of the uterus 
at the site of sanguineous effusion ; but this will be difficult to make 
out, except in women with thin and unusually lax abdominal parietes. 
.V rapid increase in the size of the uterus has been described as a sign 
by Cazeaux and others. It is not very likely that this will be appre- 
ciable toward the end of utero-gestation, as a very large amount of 
effusion would be necessary to produce it. At an earlier period of 



432 LABOR. 

pregnancy, at or about the fifth month, I made it out very distinctly 
in a case in my own practice. It obviously must have occurred to an 
enormous extent in a case related by Chevalier, in which post-mortem 
Cesarean section was performed under the impression that the -preg- 
nancy had advanced to term, but only a three months' foetus was found, 
imbedded in coagula which distended the uterus to the size of a nine 
months' gestation. 1 Labor pains may be entirely absent. If present, 
they are generally feeble, irregular, and inefficient. 

Differential Diagnosis. — The only condition, beside ordinary syn- 
cope, likely to be confounded with this form of hemorrhage, is rupture 
of the uterus, to which the intense pain and profound collapse induce 
considerable resemblance. The latter rarely occurs until after labor 
has been some time in progress, and after the escape of the liquor 
amnii ; whereas hemorrhage usually occurs either before labor has 
commenced, or at an early stage. The recession of the presentation, 
and the escape of the foetus into the abdominal cavity, in cases of rup- 
ture, will further aid in establishing the diagnosis. 

Prognosis. — The prognosis, when blood escapes externally, is, on 
the whole, not unfavorable. The nature of the case is apparent, and 
remedial measures are generally adopted sufficiently early to prevent 
serious mischief. It is different with the concealed form, in which 
the mortality is very great. Out of Goodell's 106 cases, no less than 
fifty-four mothers died. This excessive death-rate is, no doubt, partly 
due to the fact that extreme prostration often occurs before the exist- 
ence of hemorrhage is suspected, and partly to the accident generally 
happening in women of weakly and diseased constitution. The prog- 
nosis to the child is still more graye. Out of 107 children, only six 
were born alive. The almost certain death of the child may be ex- 
plained by the fact that, when blood collects between the uterus and 
the placenta, the foetal portion of the latter is probably lacerated, and 
the child then also dies from hemorrhage. 

Treatment. — In this, as in all other forms of puerperal hemor- 
rhage, the great haemostatic is uterine contraction, and that we must 
try to encourage by all possible means. The first thing to be done, 
whether the hemorrhage be apparent or concealed, is to rupture the 
membranes. If the loss of blood be only slight, this may suffice to 
control it, and the case may then be left to Nature. A firm abdominal 
binder should, however, be applied to prevent any risk of blood col- 
lecting internally, as there is nothing to prevent its filling the uterine 
cavity after the membranes are ruptured. Contraction may be further 
advantageously solicited by uterine compression, and by the adminis- 
tration of full doses of ergot. If hemorrhage continue, or if we have 
any reason to suspect concealed hemorrhage, the sooner the uterus is 
emptied the better. If the os be sufficiently dilated, the best practice 
will be to turn without further delay, using the bi-polar method if 
possible. If the os be not open enough, a Barnes bag should be in- 
troduced, while firm pressure is kept up to prevent uterine accumula- 
tion. Should the collapsed condition of the patient be very marked, 

i Journ. de Med. Clin, et Pharm., torn. xxi. p. 363. 



HEMORRHAGE AFTER DELIVERY. 433 

the mere shock of the operation might turn the scale against her. 
Under such circumstances it may be better practice to delay further 
procedure until, by the administration of stimulants, warmth, etc., we 

have succeeded in producing some amount of reaction, keeping up, in 
the meanwhile, firm pressure on the uterus. Should the head be low 
down in the pelvis, it may be easier to complete labor by means of the 
forceps. 



CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

Its Importance. — Hemorrhage during, or shortly after, the third 
stage of labor is one of the most trying and dangerous accidents con- 
nected with parturition. Its sudden and unexpected occurrence just 
after the labor appears to be happily terminated, and its alarming 
effect on the patient, who is often placed in the utmost danger in a few 
moments, tax the presence of mind and the resources of the practi- 
tioner to the utmost, and render it an imperative duty on everyone 
who practises midwifery to make himself thoroughly acquainted with 
its causes, and preventive and curative treatment. There is no emer- 
gency in obstetrics which leaves less time for reflection and consulta- 
tion, and the life of the patient will often depend on the prompt and 
immediate action of the medical attendant. 

Frequency of Post-partum Hemorrhage. — Postpartum hemor- 
rhage is one of the most frequent complications of delivery. I do not 
know of any statistics which enable us to judge with accuracy of its 
frequency, but I believe it to be an unquestionable fact that, especially 
in the upper ranks of society, it is very common indeed. This is 
probably due to the effects of civilization, and to the mode of life of 
patients of that class, whose whole surroundings tend to produce a 
lax habit of body which favors uterine inertia, the principal cause of 
post-partum hemorrhage. In the report of the Registrar-General for 
the five years from 1872 to 1876, 3524 deaths are attributed to flood- 
ing. The majority of these must have been caused by post-partum 
hemorrhage, although some may have been from other forms. 

Fortunately, it is, to a great extent, a preventable accident. I 
believe this fact cannot be too strongly impressed on the practitioner. 
If the third stage of labor be properly conducted, if every case be 
treated, as every case ought to be, as if hemorrhage were impending, 
it would be much more infrequent than it is. It is a curious fact 
that post-partum hemorrhage is much more common in the practice of 
some medical men than in that of others ; the reason being that those 
who meet with it often, are careless in their management of their 

28 



434 LABOR. 

patients immediately after the birth of the child. That is just the 
time when the assistance of a properly qualified practitioner is of 
value, much more so than before the second stage of labor is con- 
cluded; hence, when I hear that a medical man is constantly meeting 
with severe post-partum hemorrhage, I hold myself justified, ipso 
facto, in inferring that he does not know, or does not practice, the 
proper mode of managing the third stage of labor. 

Causes. — The placenta, as we have seen, is separated by the last 
pains, and the blood, which in greater or less quantity accompanies 
the foetus, probably comes from the utero-placental vessels which are 
then lacerated. Almost immediately afterward the uterus contracts 
firmly, and, in a typical labor, assumes the hard cricket-ball form 
which is so comforting to the accoucheur to feel. (See Plate Y.) 
The result is the compression of all of the vascular trunks which 
ramify in its walls, both arteries and veins, and thus the flow of blood 
through them is prevented. By referring to what has been said as to 
the anatomy of the muscular fibres of the gravid uterus, especially at 
the placental site (p. 62), it will be seen how admirably they are 
adapted for this purpose. The arrangement of the vessels themselves 
favors the haemostatic action of uterine contraction. The large venous 
sinuses are placed in layers one above the other, in the thickness of 
the uterine walls, and they anastomose freely. When the superim- 
posed layers communicate with those immediately below them, the 
junction is by a falciform or semilunar opening in the floor of the 
vessel nearest the external surface of the uterus. Within the margins 
of this aperture there are muscular fibres, the contraction of which 
probably tends to prevent retrogression of blood from one layer of 
vessels into the other. The venous sinuses themselves are of a flattened 
form, and they are intimately attached to the muscular tissues. It is 
obvious, then, that these anatomical arrangements are eminently 
adapted to facilitate the closure of the vessels. They are, however, 
large, and are destitute of valves; and if contraction be absent, or if 
it be partial and irregular, it is equally easy to understand why blood 
should pour forth in the appalling amount which is sometimes 
observed. 

If uterine action be firm, regular, and continuous, the vessels must 
be sealed up and hemorrhage effectually prevented. This fact has 
been doubted by many authorities. Gooch was the first to describe 
what he called "a peculiar form of hemorrhage" accompanying a 
contracted womb. Similar observations have been made by other 
writers, such as Yelpeau, Kigby, and Gendrin. Simpson says, on this 
point, that strong uterine contractions "are not probably so essential 
a part in the mechanism of the prevention of hemorrhage from the 
open orifices of the uterine veins as we might a priori suppose." 1 
With regard to Gooch's cases, it has been pointed out that his own 
description proves that, however firmly the uterus may have contracted 
immediately after the expulsion of the child, it must have subse- 
quently relaxed, for he passed his hand into it to remove retained 

1 Selected Obstetric Works, p. 234. 



HEMOKKHAGE AFTER DELIVERY. 435 

clots, a manoeuvre which he could not have practised had tonic con- 
traction been present. In some of these eases the hemorrhage has 
been found to come from a laceration of the cervix. Of course, blood 
may readily escape from a mechanical injury of this kind, although 
the uterus itself be in a satisfactory state of contraction ; and the pos- 
sibility of this occurrence should always be borne in mind, [nstances 
of the successful treatment of this variety of post-partum hemorrhage 
by sutures applied to the lacerated cervix have been related by Pallen 
and others. 

Although, then, we may admit that post-partum hemorrhage is in- 
compatible with persistent contraction of the uterus, it bv no means 
follows that the converse is true. On the contrary, it is not uncom- 
mon to meet with cases in which the uterus is large, and apparently 
quite flaccid, and in which there is no loss of blood. Alternate relaxa- 
tion and contraction of the uterus after delivery are also of constant 
occurrence, and yet hemorrhage, during the relaxation, does not take 
place. The explanation no doubt is, that immediately after the birth 
of the child there was sufficient contraction to prevent hemorrhage, 
and that, during its continuance, coagula formed in the mouths of the 
uterine sinuses, by which they were sufficiently occluded to prevent 
any loss when subsequent relaxation occurred. 

In all probability both uterine contraction and thrombosis are in 
operation in ordinary cases; and we shall presently see that all the 
means employed, in the treatment of post-partum hemorrhage act by 
producing one or other of them. 

Uterine inertia after labor, then, may be regarded as the one great 
primary cause of post-partum hemorrhage ; but there are various sec- 
ondary causes which tend to produce it, one of the most frequent of 
which is exhaustion following a protracted labor. The uterus gets 
worn out by its efforts, and when the foetus is expelled, it remains in 
a relaxed state, and hemorrhage results. Over-distention of the uterus 
acts in the same way. Hence hemorrhage is very frequently met with 
when there has been an excessive amount of liquor amnii, or in mul- 
tiple pregnancies. One of the worst cases I ever met with was after 
the birth of triplets, the uterus having been of an enormous size. 
Rapid emptying of the uterus, during which there has not been suffi- 
cient time for complete separation of the placenta, often tends to the 
same result. This is the reason why hemorrhage so frequently follows 
forceps delivery, especially if the operation have been unduly hur- 
ried ; and it is one of the chief dangers in what are termed " precipi- 
tate labors." The general condition of the patient may also strongly 
predispose to it. Thus it is more often met with in women who have 
borne families, especially if they be weakly in constitution, compara- 
tively seldom in primiparae; and for the same reason that after-pains 
are most common in the former, namely, that the uterus, weakened by 
frequent childbearing, contracts inefficiently. The experience of prac- 
titioners in the tropics shows that European women, debilitated by 
the relaxing effects of warm climates, are peculiarly prone to it, and 
it forms one of the chief dangers of childbirth amongst the English 
ladies in India. 



436 



LABOR. 



Another important cause of post-partum hemorrhage is partial and 
irregular contraction of the uterus. Part of the muscular tissue is 
firmly contracted, while another part is relaxed, and the latter very 
often the placental site. This has been especially dwelt on by Simp- 
son. He says: "The morbid condition which is most frequently and 
earliest seen in connection with post-partum hemorrhage, is a state of 
irregularity and want of equability in the contractile action of different 
parts of the uterus — and, it may be, in different planes of the mus- 
cular fibres — as marked by one or more points in the organ feeling 
hard and contracted, at the same time that other portions of the 
parietes are soft and relaxed." 

One peculiar variety, which has been much dwelt on by writers, 
and is a prominent bugbear to obstetricians, is the so-called hour-glass 
contraction. This in reality seems to depend on spasmodic contraction 
of the internal os uteri, by means of which the placenta becomes 
encysted in the upper portion of the uterus, which is relaxed. On 
introducing the hand, it first passes through the lax cervical canal 
until it comes to the closed internal os, with the umbilical cord passing 
through it, which has generally been supposed to be a circular con- 
traction of a portion of the body of the uterus. 

Encystment of the placenta, however, although more rarely, unques- 
tionably takes place in a portion only of the body of the uterus 
(Fig. 153). Then apparently the placental site remains more or less 

Fig. 153. 





Irregular contraction of the uterus, with encystment of the placenta. 

paralyzed, with the placenta still attached, while the remainder of the 
body of the uterus contracts firmly, and thus encystment is produced. 

These irregular contractions of the uterus are by no means so common 
as our older authors supposed. When they do occur, I believe them 
almost invariably to depend on defective management of the third 
stage of labor. " The most frequent cause," says Rigby, 1 " is from 
over-anxiety to remove the placenta ; the cord is frequently pulled at, 



1 Bigby's Midwifery, p. 225. 



HEMORRHAGE AFTER DELIVERY. 437 

and at length the os uteri is excited to contract." A\ bile this i- being 
done, ii" attempts are probably being made to excite the fund - I 
proper action, and, therefore, the hour-glass contraction isestablis 
Johnstone 1 bas pointed out that in a large proportion i 
has been given before the expulsion of the placenta. Duncan a 
this condition : " Hour-glass contraction cannot exist unless the parts 
the contraction are in a state of inertia ; were the higher [tarts 
of the uterus even in moderate action, the hour-glass contraction would 
soon be overcome." 1 [f placental expression were always employed, if 
it were the rule to effect the expulsion of the placenta by a t 
instead of extracting it 1>\ .1:1 confident that these 

irregular and spasmodic contractions — of the influence of which in 
producing hemorrhage there can be no question — would rarely, if ever, 
be met with. It i- to be observed that, even in th< g ses, it is not 
because the uterus is in a state of partial contraction, but because it is 
in a state of partial relaxation, that hemorrhage ensues. 

Placental Adhesions. — Adhesions of the placenta to the uterine 
parietes may cause hemorrhage, especially if they be partial and the 
remainder of the placenta be detached, The frequency of these has 
been over-estimated. Many cases believed to be examples of adherent 
placentae are, in reality, only cases of placentae retained from uterine 
inertia. The experience of all who see much midwifery will probably 
corroborate the observation of Braun. that " abnormal adhesion and 
boor-glass contraction are more frequently encountered in the expe- 
rienee of the young practitioner, and they diminish in frequency in 
direct ratio to increasing years."" The cause of adhesion is often 
obscure, but it most probably results from a morbid state of the 
decidua. which is produced by antecedent disease of the uterine mucous 
membrane: then the adhesion is apt to recur in subsequent pregnancies. 
The decidua is altered and thickened, and patches of calcareous and 
fibrous degeneration may be often found on the attached surface of the 
placenta. Most frequently the placenta is only partially adherent ; 
patches of it remain firmly attached to the uterus, while the rest is 
separated; hence the uterine walls remain relaxed and hemorrhage 
frequently follows. The diagnosis and management of these very 
troublesome cases will be found described under the head of treatment 
(p. 441). 

Finally. I think it must be admitted that there are some women 
who really merit the appellation of " Flooders" which has been applied 
to them, and who. do what we may. have the most extraordinary ten- 
dency to hemorrhage alter delivery. I do not think that these cases, 
however, are by any means s< » common as some have supposed. I have 
attended several patient- who have nearly lost their lives from post- 
partum hemorrhage in former labors, some who have suffered from it 
in every preceding confinement, and I have only met with two - - 
in which the assiduous use of preventive treatment failed to avert it. 
In these (one of which I have elsewhere published in detail 4 ), in spite 

1 Glasgow Med. Journ.. 1S-S7, vol. xxvii. | 

searches in Obstetrics, i 3 Braun's Lectures, 1869. 

* Obst. Journ., 1S73-74. vol. i. p. 89. 



438 LABOK. 

of all my efforts, I could not succeed in keeping up uterine contraction, 
and the patients would certainly have lost their lives were it not for 
the means which modern improvements have fortunately placed at our 
disposal for producing thrombosis in the mouths of the bleeding 
vessels. The nature of these rare cases requires further investigation ; 
possibly they may, to some extent, be the subjects of the so-called 
hemorrhagic diathesis. 

The loss of blood may commence immediately after the birth of the 
child, before the expulsion of the placenta, or not until some time 
afterward, when the contracted uterus has again relaxed. It may 
commence gradually or suddenly ; in the latter case it may begin with 
a gush, and in the worst form the bedclothes, the bed, and even the 
floor, are deluged with the blood which, it is no exaggeration to say, 
is pouring from the patient. If now the hand be placed on the abdo- 
men, we shall miss the hard round ball of the contracted uterus, which 
will be found soft and flabby, or we may even be unable to make out 
its contour at all. If the hemorrhage be slight, or if we succeed in 
controlling it at once, no serious consequences follow ; but if it be ex- 
cessive, or if we fail to check it, the gravest results ensue. 

There are few sights more appalling to witness than one of the worst 
cases of post-partum hemorrhage. The pulse becomes rapidly affected, 
and may be reduced to a mere thread, or it may become entirely im- 
perceptible. Syncope often comes on — not in itself always an un- 
favorable occurrence, as it tends to promote thrombosis in the venous 
sinuses. Or, short of actual syncope, there may be a feeling of intense 
debility and faintness. Extreme restlessness soon supervenes, the 
patient throws herself about the bed, tossing her arms wildly above 
her head ; respiration becomes gasping and sighing, the u besoin de 
respirer" is acutely felt, and the patient cries out for more air ; the skin 
becomes deadly cold, and covered with profuse perspiration ; if the 
hemorrhage continue unchecked, we next may have complete loss of 
vision, jactitation, convulsions, and death. 

Formidable as such symptoms are, it is satisfactory to know that 
recovery often takes place, even when the powers of life seem reduced 
to the lowest ebb. If we can check the hemorrhage while there is 
still some power of reaction left, however slight, we may not unreason- 
ably hope for eventual recovery. The constitution, however, may 
have received a severe shock, and it may be months, or even years, 
before the patient recovers from the effects of only a few minutes' 
hemorrhage. A death-like pallor frequently follows these excessive 
losses, and the patient often remains blanched and exsanguine for a 
long time. 

Preventive Treatment. — The preventive treatment of post-partum 
hemorrhage should be carefully practised in every case of labor, how- 
ever normal. If the practitioner make a habit of never removing his 
hand from the uterus after the birth of the child until the placenta is 
expelled, and of keeping up continuous uterine contraction for at least 
half an hour after delivery is completed, not necessarily by friction on 
the fundus, but by simply grasping the contracted womb with the 
palm of the hand and preventing its undue relaxation, cases of post- 



HEMORRHAGE AFTER DELIVERY. 439 

partum flooding will seldom be met with. As a rule we should not, I 
think, apply the binder until at Least that time has elapsed. The 
binder is an effective means of keeping up, hut not of producing, con- 
traction, and it should never he trusted to lor the Latter purpose. If 
it be put on too soon, the uterus may relax under it, and become Idled 
with clots without the practitioner knowing anything about it ; whereas, 
this cannot possibly take place as Long as the uterine globe is held in 
the hollow of the hand. 1 have seen more than one serious case <»!' 
concealed hemorrhage result from the too common habit of putting on 
the binder immediately after the removal of the placenta. I believe 
also, as I have formerly said, that it is thoroughly good practice to 
administer a full dose of the liquid extract of ergot in all cases after 
the placenta has been expelled, to insure persistent contraction and to 
lessen the chance of blood-clots being retained in utero. 

These are the precautions which should be used in all cases alike ; 
but when we have reason to fear the occurrence of hemorrhage, from 
the history of previous labors or other cause, special care should be 
taken. The ergot should be given, and preferably in the form of the 
subcutaneous injection of ergotine, before the birth of the child, when 
the presentation is so far advanced that we estimate that labor will be 
concluded in from ten to twenty minutes, as we can hardly expect the 
drug to produce any effect in less time. Particular attention, more- 
over, should then be paid to the state of the uterus. Every means 
should be taken to insure regular and strong contraction, and it is 
advisable to rupture the membranes early, as soon as the os is dilated 
or dilatable, to insure stronger uterine action. If any tendency to 
relaxation occur after delivery, a piece of ice should be passed into the 
vagina or into the uterus. Should coagula collect in the uterus, they 
may be readily expelled by firm pressure on the fundus, and the finger 
should be passed occasionally up to the cervix, and any which are felt 
there should be gently picked away. 

We should be specially on our guard in all cases in which the pulse 
does not fall after delivery. If it beat at 100 or more some ten minutes 
or a quarter of an hour after the birth of the child, hemorrhage not 
unfrequently follows ; and hence it is a good practical rule, which may 
save much trouble, that a patient should never be left unless the pulse 
has fallen to its natural standard. 

Curative Treatment. — As there are only two means which Nature 
adopts in the prevention of post-partum hemorrhage, so the remedial 
measures also may be divided into two classes : 1. Those which act 
by the production of uterine contraction. 2. Those which act by pro- 
ducing thrombosis in the vessels. Of these the first are the most 
commonly used ; and it is only in the worst cases, in which they have 
been assiduously tried and have failed, that we resort to those coming 
under the second heading. 

The patient should be placed on her back, in which position we can 
more readily command the uterus, as well as attend to her general 
state. If the uterus be found relaxed and full of clots, by firmly 
grasping it in the hand contraction may be evoked, its contents ex- 
pelled, and further hemorrhage at once arrested. Should this fortu- 



440 LABOR. 

nately be the case, we must keep up contraction by gently kneading 
the uterus, until we are satisfied that undue relaxation will not recur. 

The powerful influence of friction in promoting contraction cannot 
be doubted, and nothing will replace it ; no doubt it is fatiguing, but 
as long as it is effectual it must be kept up. No roughness should be 
used, as we might produce subsequent injury, but it is quite possible to 
use considerable pressure without any violence. 

Another method of applying uterine pressure has been strongly 
advocated by Dr. Hamilton, of Falkirk, and it may be serviceable 
where there is a constant draining from the uterus, and a capacious 
pelvis. It consists in passing the fingers of the right hand high up 
into the posterior cul-de-sac of the vagina, so as to reach the posterior 
surface of the uterus, while counter-pressure is exercised by the left 
hand through the abdomen. The anterior and posterior walls of the 
uterus are thus closely pressed together. 

During the time that pressure is being applied, attention can be paid 
to general treatment ; and in giving his directions to the bystanders 
the practitioner should be calm and collected, avoiding all hurry and 
excitement. A full dose of ergot should be administered, and if one 
have already been given, it should be repeated. We cannot, however, 
look upon ergot as anything but a useful accessory, and it is one which 
requires considerable time to operate. The hypodermic use of ergotine 
offers the double advantage, in severe cases, of acting with greater 
power, and much more rapidly, than the usual method of administra- 
tion. It should, therefore, always be used in preference. An aqueous 
solution of ergotinine, y^- of a grain in 10 minims, has been highly 
recommended by Chahbazain, of Paris, as acting more energetically, 
and, it has seemed to me, 1 has had a good effect. 

The sudden flow will probably have produced exhaustion and a 
tendency to syncope, and the administration of stimulants will be 
necessary. The amount must be regulated by the state of the pulse 
and the degree of exhaustion. There is no more absurd mistake, how- 
ever, than implicitly relying on the brandy bottle to check post-partum 
hemorrhage. In the w r orst cases absorption is in abeyance, and brandy 
may be poured down in abundance, the practitioner believing that he 
is rousing his patient, while he is, in fact, only filling the stomach with 
a quantity of fluid which is eventually thrown up unaltered. I have 
more than once seen symptoms, produced by the over-free use of brandy 
in slight floodings, which were certainly not those of hemorrhage. I 
remember on one occasion being summoned by a practitioner, with 
a view to transfusion, to a patient who was said to be insensible and 
collapsed from hemorrhage. I found her, indeed, unconscious ; but 
with a flushed face, a bounding pulse, a firmly contracted uterus, and 
deep stertorous breathing. On inquiry I ascertained that she had 
taken an enormous quantity of brandy, which had brought on the 
coma of profound intoxication, while the hemorrhage had obviously 
never been excessive. 

The hypodermic injection of sulphuric ether is a remedy of great 

i Obst. Trans, for 1882, vol. xxiv. p. 286. 



HEMORRHAGE AFTER DELIVERY. Ill 

value as a powerful stimulant in cases In which exhaustion is very 
great. It has the advantage of acting rapidly, and of being capable 

of administration when the patient is unable to swallow. A fluid 
drachm may be injected into the nates, or thigh, and the injection may 
be repeated as the state of the patient may require. 

The window should be tin-own widely open, to allow a current of 
fresh cold air to circulate freely through the room. The pillows should 
be removed, the head kept low, and the patient should be assiduously 
fanned. It is often found to be useful to raise the feet of the l>ed on 
blocks of wood, or books, so as to have the head lower than the pelvis. 
This will favor the current of blood to the head, and lessen the ten- 
dency to syncope. 

If bleeding continue, or if it commence before the placenta is ex- 
pelled, the hand should be carefully and gently passed into the uterus, 
and its cavity cleared of its contents. The mere presence of the hand 
within the uterus is a powerful inciter of uterine action. When the 
placenta is retained it is the more essential, as the hemorrhage cannot 
possibly be checked as long as the uterus is distended by it. During 
the operation the uterus should be supported by the left hand externally, 
and, by using the two hands in concert, the chances of injuring the 
textures are greatly lessened. 

Treatment of Hour-glass Contraction. — If the so-called " hour- 
glass contraction " be present, or if the placenta be morbidly adherent, 
the operation will be more difficult, and will require much judgment 
and care. The spasmodic contraction of the inner os in the former 
case may generally be overcome by gentle and continuous pressure of 
the fingers passed within the contraction, while the uterus is supported 
from without. By this means, too, further hemorrhage can in most 
cases be controlled until the spasm is sufficiently relaxed to admit of 
the passage of the hand. 

Signs of Adherent Placenta. — There are no very reliable signs to 
indicate morbid adhesion of the placenta, previous to the introduction 
of the hand. The following are the symptoms as laid down by Barnes, 
any of which might, however, accompany non-detachment of the 
placenta unaccompanied by adhesion : " You may suspect morbid 
adhesion if there have been unusual difficulty in removing the placenta 
in previous labors ; if during the third stage the uterus contracts at 
intervals firmly, each contraction being accompanied by blood, and 
yet, on following up the cord, you feel the placenta in utero ; if, on 
pulling on the cord, two fingers being pressed into the placenta at the 
root, you feel the placenta and uterus descend in one mass, a sense of 
dragging pain being elicited ; if during a pain the uterine tumor does 
not present a globular form, but is more prominent than usual at the 
place of placental attachment." ! 

Treatment of Adherent Placenta. — The artificial removal of an 
adherent placenta is always a delicate and anxious operation, which, 
however carefully performed, must of necessity expose the patient to 
the risk of injury to the uterine structures, and of leaving behind por- 

1 Obstetric Operations, p. 440- 



442 LABOR. 

tions of placental tissue, which may give rise to secondary hemorrhage 
or saprsemia. The cord will guide the hand to the site of attachment, 
and the lingers must be very gently insinuated between the lower edge 
of the placenta and the uterine wall ; or, if a portion be already 
detached, we may commence to peel off the remainder at that spot. 
Supporting the uterus externally, we carefully pick off as much as 
possible, proceeding with the greatest caution, as it is by no means easy 
to distinguish between the placenta and the uterus. At the best, it is 
far from easy to remove all, and it is wiser to separate only what we 
readily can than to make too protracted efforts at complete detachment. 
When it is found to be impossible to detach and remove the whole or 
a great part of the placenta, Ave cannot but look upon the further 
progress of the case with considerable anxiety. The retained portions 
may be, ere long, spontaneously detached and expelled, or they may 
decompose and give rise to fetid discharge and septic infection. Such 
cases must be treated by antiseptic intra-uterme injections, so as to 
lessen the risk of absorption as much as possible ; but until the retained 
masses have been expelled, and the discharge has ceased, the patient 
must be considered to be in considerable danger. In a few rare cases, 
there is reason to believe that considerable masses of retained placental 
tissue have been entirely absorbed. It is difficult to understand so 
strange a phenomenon, but several well-authenticated cases are re- 
corded in which there seems no reason to doubt that the retained 
placenta was removed in this way. 1 

Various means are used for exciting uterine contraction by reflex 
stimulation. Amongst the most important of these is cold. In 
patients who are not too exhausted to respond to the stimulus applied, 
it is of extreme value. But, to be of use, it should be used intermit- 
tently, and not continuously. Pouring a stream of cold water from a 
height on the abdomen is a not uncommon, but bad practice, as it 
deluges the patient and bedding in water, which may afterward act 
injuriously. Flapping the lower part of the abdomen Avith a wet 
towel is less objectionable. Ice can generally be obtained, and a piece 
should be introduced into the uterus. This is a very powerful haemo- 
static, and often excites strong action when other means fail. I con- 
stantly employ it, and have never seen any bad results follow. A 
large piece of ice may also be held over the fundus, and removed, 
and reapplied from time to time. Iced water may be injected into 
the rectum. A very powerful remedy is washing out the uterine 
cavity with a stream of cold water, by means of the vaginal pipe of a 
Higginson's syringe carried up to the fundus. Another means of 
applying cold, said to be very effectual, is the application of the ether 
spray, such as is used for producing local anaesthesia, over the lower 
part of the abdomen. 2 All these remedies, however, depend for their 
good results on the fact of the patient being in a condition to respond 
to stimulus ; and their prolonged use, if they fail to excite contraction 
rapidly, will certainly prove injurious. Rigby used to look upon the 

1 See an interesting paper by Dr. Thrush on " Retention of the Placenta in Labor at Term," 
Amer. Journ. of Obstet., 1877. vol. x. pp. 389, 506. 

2 Griffiths : Practitioner, 1877, vol. xviii. p. 176. 



HEMORRHAGE AFTER DELIVERY. 448 

application of the child to the breasl as one of the most certain inciters 
of uterine action. It may be of service alter the hemorrhage lias been 

checked, in keeping up tonic contraction, and should therefore not he 
omitted \ but we certainly cannot waste time in inducing the child to 
Buck in the face of the actual emergency. 

[ntra-uterine injection of hoi water, at a temperature of from 100 
to 120°, has been highly recommended as a powerful means of arrest- 
ing post-partum hemorrhage, often proving effectual when all other 
treatment has failed. ['] The number of published cases in which it 
has proved of great value is now considerable. The late master of 
the Rotunda, Dr. Lombe Atthill, has recorded sixteen cases 2 in which it 
checked hemorrhage at once, in many of which ergot, ice, and other 
means had failed. He speaks of it as especially useful in those trouble- 
some cases in which the uterus alternately relaxes and hardens, and 
resists all our efforts to produce permanent contraction. Its superiority 
to eold water lias been well shown by Milne Murray 3 by means of ex- 
periments on preguant and non-pregnant rabbits, which proved that 
while eold applications produce a temporary contraction, when applied 
for any length of time they rapidly exhaust the excitability of the uterine 
muscle, while the reverse effect is produced when hot water is used. 
My own experience of this treatment is very favorable. I have now 
used it in many cases, in some of which the tendency to hemorrhage 
was very great, and in every instance it has at once produced strong 
uterine action and instantly checked the flow. It is, moreover, much 
more agreeable to the patient than cold applications. It is advisable 
to add a few drops of creolin to the hot water, which is in itself a 
good antiseptic, and is said to be also a powerful styptic. I think it 
cannot be doubted that we have in these warm irrigations a valuable 
addition to our methods of treating uterine hemorrhage. 

The late Dr. Earle pointed out* that a distended bladder often pre- 
vents contraction, and to avoid the possibility of this the catheter 
should be passed. 

Since 1887 plugging the uterine cavity with iodoform gauze, or, 
when this is not at hand, with pledgets of cotton-wool soaked in car- 
bolic solution, has been thoroughly advocated in Germany, chiefly by 
Duhrssen, 5 but since the publication of his paper a large number of 
successful cases have been published 6 in which this treatment has 
been adopted, so that it must be admitted as a useful resource in cer- 
tain intractable cases. It seems to act in two ways : first, by exciting 
energetic and continuous uterine contractions ; and next, by direct 
pressure on the bleeding part. In applying the plugs, the patient 
should be placed on her back, the cervix drawn down with a volsella, 
and long strips of gauze passed up to the fundus with ovum forceps, 
until the uterine cavity is completely packed. The vagina should be 
subsequently plugged with pledgets of cotton-wool soaked in glycerin 
or carbolized water and dusted with iodoform. The pings may be 

f 1 The proper temperature is 115°. Water at a temperature of 100° has a tendency to favor the 
hemorrhage.— Ed.] 
2 Lancet, February 9, 1878. 3 Edin. Med. Journ., 18Sf»-S7, pp. 131, 215. 

4 Earle : Flooding after Delivery, p. 163. 6 Volkmannische Sammlung, No. 347. 

e See Year-book of Treatment, 1891. 



444 LABOR. 

allowed to remain in the litems from eight to twelve hours, by which 
time all risk of recurrence of the hemorrhage will be at an end. I 
have no personal experience of this treatment, but the evidence in its 
favor is strong. It is clearly one which can only be resorted to in very 
intense cases of hemorrhage when all other means have failed. It will 
obviously be essential to carefully watch the uterus, to make sure that 
blood is not escaping into and distending its cavity above the plug. 
If the uterine cavity should be only partially or ineffectually filled, 
concealed internal hemorrhage might very readily be going on without 
the practitioner's knowledge. 

Compression of the abdominal aorta is highly thought of by many 
Continental authorities, but it is little known or practised in this 
country. It has been objected to by some on the theoretical ground 
that the hemorrhage is chiefly venous, not arterial, and that it would 
only favor the reflux of venous blood into the vena cava. Cazeaux 
points out that, on account of the close anatomical relations between 
the aorta and the vena cava, it is hardly possible to compress one 
vessel without the other. The backward flow of blood, therefore, 
through the vena cava may also be thus arrested. There is strong 
evidence in favor of the occasional utility of compression. Its chief 
recommendation is that it can be practised immediately, and by an 
assistant, who can be shown how to apply the pressure. It is most 
likely to prove useful in sudden and severe hemorrhage, and, if it 
only control the loss for a few moments, it gives us time to apply 
other methods of treatment. As a temporary expedient, therefore, it 
should be borne in mind, and adopted when necessary. It has the 
great advantage of supplementing, without superseding, other and 
more radical plans of treatment. The pressure is very easily applied, 
on account of the lax state of the abdominal walls. The artery can 
readily be felt pulsating above the fundus uteri, and can be com- 
pressed against the vertebra? by three or four fingers applied length- 
wise. Baudelocque, who was a strong advocate of this procedure, 
stated that he had, on several occasions, controlled an otherwise 
intractable hemorrhage in this way, and that he, on one occasion, kept 
up compression for four consecutive hours. Cazeaux believes that 
compression of the aorta may have a further advantageous effect in 
retaining the mass of the blood in the upper part of the body, and 
thus lessening the tendeucy to syncope and collapse. If an aortic 
tourniquet, such as is used for compressing the vessel in cases of 
aneurism, could be obtained, it might be used with advantage in such 
cases. 

If a battery is at hand the faradic current may be used, and it is said 
to be a very powerful agent in inducing uterine contraction, one pole 
being introduced into the uterus, the other applied over it through the 
abdominal parietes. 

When the hemorrhage has been excessive, and there is profound 
exhaustion, firm bandaging of the extremities, by preference with 
Esmarch's elastic bandages if they can be obtained, may be advan- 
tageously adopted, with the view of retaining the blood as much as 
possible in the ;runk, and thus lessening the tendency to syncope. As 



11 KMORRHAGE AFTER DELIVERY. 145 

a temporary expedienl in the worst class of cases it may occasionally 
prove of service. 

[Lives of patients in extremis have been saved by the expedient of 
raising the body of the woman and lowering her head, so as to turn 

the current of blood toward the brain. This may have to be repeated 
several times in the treatment of a ease where attacks of syncope indi- 
cate it. A bladder containing ice may be held under the hand of the 
operator over the abdomen and above the fundus uteri, and compres- 
sion made upon the uterus and aorta at the same time. In one case I 
was forced, by the long-continued inertia of the uterus and the ten- 
dency to a return of hemorrhage, to keep up this form of compression 
for six and a half hours. The hand of the operator should be protected 
by a compress of flannel, or he may have an attack of local neuralgia, 
or possibly rheumatism, in his arm. — Ed.] 

Supposing these means fail, and the uterus obstinately refuses to 
contract in spite of all our efforts — and, do what we may, cases of this 
kind will occur — the only other agent at our command is the applica- 
tion of a powerful styptic to the bleeding surface to produce throm- 
bosis in the vessels. "The latter," says Dr. Ferguson, 1 alluding to 
this means of arresting hemorrhage, " appears to be the sole means of 
safety in those cases of intense flooding in which the uterus flaps about 
the hand like a wet towel. Incapable of contraction for hours, yet 
ceasing to ooze out a drop of blood, there is nothing apparently be- 
tween life and death but a few soft coagula plugging up the sinuses." 
These form but a frail barrier indeed, but the experience of all who 
have used the injection of a solution of perchloride of iron in such 
cases proves that they are thoroughly effectual, and their introduction 
into practice is one of the greatest improvements in modern mid- 
wifery. Although this method of treating these obstinate cases is not 
new, since it was practised long ago in Germany, its adoption in this 
country is unquestionably due to the energetic recommendation of Dr. 
Barnes. The dangers of the practice have been strongly insisted on, 
and with a degree of acrimony that is to be regretted, but I know of 
only one published case in which its use has been followed by any 
evil effects. Its extraordinary power, however, of instantly check inu- 
tile most formidable hemorrhage has been demonstrated by the unani- 
mous testimony of all who have tried it. As it is not proposed by 
anyone that this means of treatment should be employed until all 
ordinary methods of evoking contraction have failed, and as, in cases 
of this kind, the lives of the patients are of necessity imperilled, we 
should be fully justified in adopting it, even if its possibly injurious 
effects had been much more certainly proved. It is surely at any time 
justifiable to avoid a great and pressing peril by running a possible 
chance of a less one. Whenever, therefore, we have tried the plans 
above indicated in vain, no time should be lost in resorting to this 
expedient. No practitioner should attend a case of midwifery without 
having the necessary styptic with him. The best and most easily 
obtainable form of using the remedy is the "liquor ferri perchloridi 

1 Preface to Gocch " On Diseases of Women." p. xlii. New Sydenham Society, 1859. 



446 LABOR. 

fortior" of the London Pharmacopoeia, which should be diluted for 
use with six times its bulk of water. This is certainly better than a 
weaker solution. The vaginal pipe of a Higginson's syringe, through 
which the solution has once or twice been pumped to exclude the air, 
is guided by the hand to the fundus uteri, and the fluid injected gently 
oyer the uterine surface. The loose and flabby mucous membrane is 
instantaneously felt to pucker up, all the blood with which the fluid 
comes in contact is coagulated, and the hemorrhage is immediately 
arrested. I think it is of importance to make sure that the uterus and 
vagina are emptied of clots before injection. In the only cases in 
which I have seen any bad symptoms follow, this precaution had been 
neglected. The iron hardened all the coagula, which remained in utero, 
and saprsemia supervened ; which, however, disappeared after the clots 
had been broken up and washed away by intra-uterine antiseptic in- 
jections. After Ave have resorted to this treatment, all further pressure 
on the uterus should be stopped. "V\ T e must remember that Aye haA^e 
now abandoned contraction as a haemostatic, and are trusting to throm- 
bosis, and that pressure might detach and lessen the coagula Avhich are 
preventing the escape of blood. 

Other local astringents may be eA T entually found to be of use. 
Tincture of matico possibly might be serA T iceable, although I am not 
aware that it has been tried. The styptic properties of creolin haA^e 
already been mentioned. Dupierris has adA T ocated tincture of iodine, 
and has recorded twenty-four cases in Avhich he employed it, in all 
without accident, and Avith a successful issue. Penrose 1 strongly 
recommends common vinegar, Avhich has the advantage of being 
ahvays readily obtainable. He speaks highly of its haemostatic effect. 
He soaks a clean handkerchief in it, and introduces it by the hand 
into the uterine caA T ity, and squeezes it OA T er the endometrium. He 
says : " The effect of the A T inegar flowing o\ T er the sides of the cavity 
of the uterus and A T agina is magical. The relaxed and flabby uterine 
muscle instantly responds. The organ assumes Avhat is called its 
gizzard-like feel, shrinking doAvn upon and compressing the operating 
hand, and in the A T ast majority of cases the hemorrhage ceases in- 
stantly." 2 This is certainly Avorth trying before the iron solution, 
Avhich is not, as Ave haA^e seen, devoid of certain risks. 

Hemorrhage from Laceration of Maternal Structures. — A Avord 
may here be said as to the occasional dependence of hemorrhage after 
deliA T ery on laceration of the cerA T ix or other injury to the maternal 
soft parts. Duncan has narrated a case in Avhich the bleeding came 
from a ruptured perineum. If hemorrhage continues after the uterus 
is permanently contracted, a careful examination should be made to 
astertain if any such injury exist. Most generally the source of bleed- 
ing is the cerATix, and the flow can be readily arrested by SAvabbing 
the injured textures Avith a sponge saturated in a solution of the per- 
chloride. 

1 Trans. Amer. Gyn. Soc, vol. iii. p. 148. 

[ 2 This remedy was used as a uterine injection with signal effect in a case of violent post-partum 
hemorrhage by a French surgeon in country practice in the days of Astruc, who wrote of it in 
1765 (Maladies des Femmes, vol. iv. p. 227).— Ed.] 



HEMORRHAGE A.FTER DELIVERY. 447 

Secondary Treatment. — The secondary treatment of post-partum 
hemorrhage is of importance. When reaction commences, a train of 
distressing symptoms often show themselves, such as intense and 
throbbing headache, great intolerance of light and sound, and general 
nervous prostration ; and, when these have passed away, we have to 
deal with the more chronic effects of profuse loss of blood. Nothing 
is so valuable in relieving these symptoms as opium. It is the best 
restorative that can he employed, but it must be administered in larger 
doses than usual. Thirty to forty drops of Battley's solution should 
be given by the mouth or in an enema. At the same time the patient 
should be kept perfectly still and quiet, in a darkened room, and the 
visits of anxious friends strictly forbidden. Strong beef-essence or 
gravy soup, milk, or eggs beaten up with milk, and similar easily 
absorbed articles of diet, should be given frequently, and iu small 
quantities at a time. Stimulants will be required according to the 
state of the patient, such as warm brandy-and- water, port wine, etc. 
Rest in bed should be insisted on, and continued much beyond the 
usual time. Eventually the remedies which act by promoting the 
formation of blood, such as the various preparations of iron, will be 
found useful, and may be required for a length of time. 

Under the head of Transfusion, I have separately treated the appli- 
cation of that last resource in those desperate cases in which the loss 
of blood has been so excessive as to leave no other hope. 

Secondary Post-partum Hemorrhage. — In the majority of cases, 
if a few hours have elapsed after delivery without hemorrhage, we 
may consider the patient safe from the accident. It is by no means 
very rare, however, to meet with even profuse losses of blood coming 
on in the course of convalescence, at a time varying from a few hours 
or days up to several weeks after delivery. These cases are described 
as examples of secondary hemorrhage, and they have not received an 
at all adequate amount of attention from obstetric writers, inasmuch 
as they often give rise to very serious, and even fatal results, and are 
always somewhat obscure in their etiology and difficult to treat. We 
owe almost all our knowledge of this condition to an excellent paper 
by Dr. McClintock, of Dublin, who has collected characteristic exam- 
ples from the writings of various authors, and accurately described the 
causes which are most apt to produce it. 

We must, in the first place, distinguish between true secondary hem- 
orrhage and profuse lochial discharge continued for a longer time 
than usual. The latter is not a very uncommon occurrence, and is 
generally met with in eases in which involution of the uterus has 
been checked — as by too early exertion, general debility, and the like. 
The amount of the lochial discharge varies in different women. In 
some patients it habitually continues during the whole puerperal 
month, and even longer, but not to an extent which justifies us in 
including it under the head of hemorrhage. In such eases prolonged 
rest, avoidance of the erect posture, occasional small doses of ergot, 
and, it may be, after the lapse of some weeks, astringent injections of 
oak-bark or alum, will be all that is necessary in the way of treat- 
ment. 



4iS LABOR. 

True secondary hemorrhage is often sudden m its appearance aud 
serious in its effects. McClintock mentions six fatal cases, aud Mr. 
Bassett. 1 of Birmingham, has recorded thirteen examples which came 
under his own observation, two of which ended fa tally. 

The causes may be either constitutional, or some local condition of 
the uterus itself. 

Constitutional Causes. — Among the former are such as produce a 
disturbance of the vascular system of the body generally, or of the 
uterine vessels iu particular. The state of the uterine sinuses, aud the 
slight barrier which the thrombi formed in them offer to the escape 
lood, readily explain the fact of any sudden vascular congestion 
producing hemorrhage. Thus mental emotious. the sudden assump- 
tion of the erect posture, any undue exertion, the incautious use of 
stimulants, a loaded condition of the bowels, or sexual intercourse 
shortly alter delivery, may act in this way. McClintock records the 
. se of a lady in whom very profuse hemorrhage occurred on the 
twelfth day after labor, when sitting up for the first time. Peeling 
faint alter suckling, the nurse gave her some brandy, whereupon a 
gush of blood ensued, "deluging all the bedclothes and peuetratmg 
through the mattress so as to form a pool on the floor." Here the 
erect position, the exquisite pain caused by nursing, and the stimulat- 
ing drink, all concurred t<:> excite the hemorrhage. In another instance 
the flooding was traced to excitement produced by the sudden return 
of an old lover «:,n the eighth day after labor. Moreau especially 
dwells on the inrluen oe of "_■ :_ mgestion produced by a loaded con- 
dition of the rectum. Constitutional affections producing general 
debility and an impoverished state of the blood, probably also may 
have the same effect. Blot specially mentions albuminuria as one of 
these, and Saboia states that in Brazil secondary hemorrhage is a com- 
mon symptom of miasmatic poisoning, and can only be cured by 
change of air and the free use of quinin 

Local Causes. — Local conditions seem, however. t<:> be the more 
lent factors in the production of secondary hemorrhage. These 
may be generally classed under the following heads : 

1. Irregular and inefheient contraction of the uterus. 

2. Clots in the uterine cavity. 

3. Portions of retained placenta or membranes. 

4. Betroriexim of the uterus. 

5. Laceration or inflammatory state of the cervix. 

6. Thrombosis or hrernatoeele of the cervix or vulva, 

7. Inversion of the uterus. 

8. Fibroid tumors or polypus of the uterus. 

The first four of these need only now be considered, the others being 
described elsewhere. 

Eelaxation of the uterus aud distention of its cavity by coagula may 
give rise to hemorrhage, although not so readily as immediately after 
delivery, for coagula of •> -nsiderable size are often retained in utero for 
many days after labor. The uterus will be found larger than it ought 

1 Brit. Med. Journ.. 1S72. vol. li. pp. 216, 491. 

2 Saboia \ Traite des Accouchements, p. 819 



HEMORRHAGE A.FTIR DELIVERY. I 111 

to be, and tender on pressure. Usually the coagnla are expelled with 
severe after-pain-; bat this may n«>t take place, and hemorrhage may 
ensue several days after delivery. Or there may be only a relaxed 
state of the uterus without retained coagula. Bassetl relates four 
traced to these causes, and several illustrations will be found in 
McClintock's paper. Portions of retained placenta or membranes are 
more frequent causes. The retention may be due to carelessness on 
the part of the practitioner, especially if he have removed the placenta 
by traction, and failed to satisfy. himself of its integrity. It may, 
however, often be due to circumstances entirely beyond his control ; 
such as adherent placenta, which it is impossible to remove without 
leaving portions in ufero, or more rarely placenta succenturia. In the 
latter ease there is a small supplementary portion of placental tissue 
developed entirely separate from the general mass, and it may remain 
in utero without the practitioner having the least suspicion of its exist- 
ence. Portions of the membranes are very apt to be left in utero. It 
is to prevent this that they should be twisted into a rope, and extracted 
very gently after expression of the placenta. Hemorrhage from these 
causes generally does not occur ttntil at least a week after delivery, and 
it may not do so until a much longer time has elapsed. In four cases 
recorded by Mr. Bassett, it commenced on the tenth, twelfth, four- 
teenth, and thirty-second day. It may come on suddenly, and con- 
tinue ; or it may stop, and recur frequently at short intervals. In my 
experience retention of portions of the placenta is very common after 
abortion, when adhesions are more generally met with than at term. In 
addition to the hemorrhage there is often a fetid discharge, due to de- 
composition of the retained portion, and possibly more or less marked 
septic symptoms, which may aid in the diagnosis. The placenta or 
membranes may simply be lying loose as foreign bodies in the uterine 
cavity ; or they may be organically attached to the uterine walls, when 
their removal will not be so easily effected. 

Barnes has especially pointed out the influence of retroflexion of the 
uterus in producing secondary hemorrhage, 1 which seems to act by 
impeding the circulation at the point of flexion, and thus arresting the 
process of involution. 

Treatment. — In every case in which secondary hemorrhage occurs 
to any extent, careful investigation into the possible causes of the 
attack, and an accurate vaginal examination, are imperatively required. 
If it be due to general and constitutional canses only, Ave must insist 
on the most absolute rest on a hard bed in a cool room, and on the 
absence of all causes of excitement. The liquid extract of ergot will 
be very generally useful in 5j doses repeated every six hours. Mc- 
Clintock strongly recommends the tincture of Indian hemp, which 
mav be advantaireouslv combined with the ergot, in doses of ten or 
fifteen minims, suspended in mucilage. Astringent vaginal pessaries 
of matico or perchloride of iron may be used. Special attention should 
be paid to the state of the bowels, and if the rectum be loaded, it 
should be emptied by enemata. In more chronic cases a mixture of 

1 Obstetric Operations, p. 192. 
29 



450 LABOR. 

ergot, sulphate of iron, and small doses of sulphate of magnesia will 
prove very serviceable. This is more likely to be effectual when the 
bleeding is of an atonic and passive character. McClintock speaks 
strongly in favor of the application of a blister over the sacrum. 
When the hemorrhage is excessive, more effectual local treatment will 
be required. Cazeaux advises plugging of the vagina. Although this 
cannot be considered so dangerous as immediately after delivery, inas- 
much as the uterus is not so likely to dilate above the plug, still it is 
certainly not entirely without risk of favoring concealed internal hem- 
orrhage. If it be used at all, the uterine cavity should be plugged 
with iodoform gauze as well as the vagina, and a firm abdominal pad 
should be applied, so as to compress the uterus; and the abdomen 
should be examined from time to time, to insure against the possibility 
of uterine dilatation. With these precautions the plug may prove of 
real value. In any case of really alarming hemorrhage I should be 
disposed rather to trust to the application of styptics to the uterine 
cavity. The injection of fluid in bulk, as after delivery, could not be 
safely practised, on account of the closure of the os and the contraction 
of the uterus. But there can be no objection to swabbing out the 
uterine cavity with a small piece of sponge attached to a handle, and 
saturated with tincture of iodine or with a solution of the perchloride 
of iron. There are few cases which will resist this treatment. 

If we have reason to suspect retained placenta or membranes, or if 
the hemorrhage continue or recur after treatment, a careful exploration 
of the interior of the womb will be essential. On vaginal examination, 
we may possibly feel a portion of the placenta protruding through the 
os, which can then be removed without difficulty. If the os be closed 
it must be dilated with Hegar's dilators, and the uterus can then be 
thoroughly explored. This ought to be done under chloroform, as it 
cannot be effectually accomplished without introducing the whole hand 
into the vagina, which necessarily causes much pain. If the placenta 
or membranes be loose in the uterine cavity, they may be removed at 
once ; or if they be organically attached, they may be carefully picked 
off. The uterus should at the same time, as long as the os remains 
patulous, be thoroughly washed out with creolin and water, or with a 
1 in 2000 solution of perchloride of mercury, to diminish the risk of 
saprsemia. 

Retroflexion can readily be detected by vaginal examination, and 
the treatment consists in careful reposition with the hand, and the 
application of a large-sized Hodge's pessary. 



RUPTURE UK THE UTERUS. 101 



CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Rupture of the uterus is one of the most dangerous accidents of 
labor, and until of late years it has been considered almost Qecessarily 
fatal and beyond the reach of treatment. Fortunately it is not of very 
frequent occurrence, although the published statistics vary so much 
that it is by no means easy to arrive at any conclusion on this point. 
The explanation is, no doubt, that many of the tables confound partial 
and comparatively unimportant lacerations of the cervix and vagina 
with rupture of the body and fundus. Jt is only in large lying-in 
institutions, where the results of cases are accurately recorded, that 
anything like reliable statistics can be gathered, for in private practice 
the occurrence of so lamentable an accident is likely to remain unpub- 
lished. To show the difference between the figures given by authori- 
ties, it mav be stated that, while Burns calculates the proportion to be 
1 in 940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 
in 1331, and Lehmann as 1 in 2433. Dr. Jolly, of Paris, has pub- 
lished an excellent thesis containing much valuable information. 1 He 
finds that out of 782,741 labors, 230 ruptures, excluding those of the 
vagina or cervix, occurred — that is, 1 in 3403. 

Lacerations may occur in any part of the uterus — the fundus, the 
body, or the cervix. Those of the cervix are comparatively of small 
consequence, and occur, to a slight extent, in almost all first labors. 
Onlv those which involve the supra-vaginal portion are of really serious 
import. Ruptures of the upper part of the uterus are much less fre- 
quent than of the portion near the cervix ; partly, no doubt, because 
the fundus is beyond the reach of the mechanical causes to which the 
accident can not unfrequently be traced, and partly because the lower 
third of the organ is apt to be compressed between the presenting 
part and the bony pelvis. The site of placental insertion is said by 
Madame La Chapelle to be rarely involved in the rupture, but it does 
not always escape, as numerous recorded cases prove. The most fre- 
quent seat of rupture is near the junction of the body and neck, either 
anteriorly or posteriorly, opposite the sacrum, or behind the symphysis 
pubis ; but it may occur at the sides of the lower segment of the uterus. 
In some eases the entire cervix has been torn away, and separated in 
the form of a ring. 

The laceration may be partial or complete, the latter being the more 
common. The muscular tissue alone may be torn, the peritoneal coat 
remaining intact; or the converse may occur, and then the peritoneum 
is often fissured in various directions, the muscular coat being unini- 

1 Rupture Uterine pendant le Travail, Paris, 1873. 



452 LABOK. 

plicated. The extent of the injury is very variable, in some cases 
being only a slight tear, in others forming a large aperture, sufficiently 
extensive to allow the foetus to pass into the abdominal cavity. The 
direction of the laceration is as variable as the size, but it is more fre- 
quently vertical than transverse or oblique. The edges of the tear are 
irregular and jagged ; probably on account of the contraction of the 
muscular fibres, which are frequently softened, infiltrated with blood, 
and even gangrenous. Large quantities of extravasated blood will be 
found in the peritoneal cavity ; such hemorrhage, indeed, being one of 
the most important sources of danger. 

Causes. — The causes are divided into predisposing and exciting; and 
the progress of modern research tends more and more to the conclusion 
that the cause which leads to the laceration could only have operated 
because the tissue of the uterus was in a state predisposed to rupture, 
and that it would have had no such effect on a perfectly healthy organ. 
"What these predisposing changes are, and how they operate, is yet far 
from being known, and the subject offers a fruitful field for pathological 
investigation. 

It is generally believed that lacerations are more common in mul- 
tiparas than in primiparse. Tyler Smith contended that ruptures are 
relatively as common in first as in subsequent labors, while Bandl 1 
found that only 64 cases out of 546 ruptures were in primiparse. 
Statistics are not sufficiently accurate or extensive to justify a positive 
conclusion, but it is reasonable to suppose that the pathological changes 
presently to be mentioned as predisposing to laceration are more likely 
to be met with in women whose uteri have frequently undergone the 
alteration attendant on repeated pregnancies. Age seems to have con- 
siderable influence, as a large proportion of cases have occurred in 
women between thirty and forty years of age. 

Alterations in the tissues of the uterus are probably of very 
great importance in predisposing to the accident, although our infor- 
mation on this point is far from accurate. Among these are morbid 
states of the muscular fibres, the result of blows and contusions during 
pregnancy ; premature fatty degeneration of the muscular tissues, n 
anticipation, as it were, of the normal involution after delivery ; fibroid 
tumors or malignant infiltration of the uterine walls, which either 
produce a morbid state of the tissues, or act as an impediment to the 
expulsion of the foetus. The importance of such changes has been 
specially dwelt on by Murphy in England and by Lehmann in 
Germany, and it is impossible not to concede their probable influence 
in favoring laceration. However, as yet these views are founded more 
on reasonable hypothesis than on accurately observed pathological facts. 

Another and very important class of predisposing causes are those 
which lead to a want of proper proportion between the pelvis and the 
foetus. 

Deformity of the pelvis has been very frequently met with in 
cases in which the uterus has ruptured. Thus out of 19 cases carefully 
recorded by Radford, 2 the pelvis was contracted in 11, or more than 

1 Ueber Ruptur der Gebarmutter. Wien, 1815. 2 Obst. Trans., 1867, vol. viii. p. 150. 



RUPTURE OF THE EJTE RUS, 



453 



one-halt'. Radford makes the carious observation thai ruptures seem 
more likely to occur when the deformity is only slight, and he ex- 
plains this by supposing that in slight deformities the lower segment 

of the nterns engages in the brim, and is, therefore, much subjected to 
compression ; while in extreme deformity the os and cervix uteri 

remain above the brim, the body and fundus of the uteri hanging 
down between the thighs of the mother. This explanation is reason- 
able; but the rarity with which ruptured uterus is associated with 
extreme pelvic deformity may rather depend on the infrequency of 
advanced degrees of contraction. 

Fig. 154. 




Illustrating the dangerous thinning of the lower segment of the uterus owing to non-descent 
of the head in a case of intra-uterine hydrocephalus (After Bandl.) 

Bandl, xvho has made the most important of modern contributions 
to our knowledge of the subject, points out that rupture nearly always 
begins in the lower segment of the nterns, which becomes abnormally 
stretched and distended when from any eanse the expulsion of the foetus 
is delayed. The upper portion of the litems becomes, at the same 
time, retracted and much thickened (see Fig. 154). As the pains con- 
tinue, the stretching of the lower segment, called by Spiegelberg the 
" obstetrieal cervix," becomes more and more marked, until at last its 
fibres separate and a laceration is established. The line of demarcation 
between the thickened body and the distended lower segment, known 
as the ring of Bandl, can, in such cases, be occasionally made out by 
palpation above the pubes. 



454 LABOR. 

Amongst the causes of disproportion depending on the foetus are 
either inalpresentation, in which the pains cannot effect expulsion, or 
undue size of the presenting part. In the latter way may be explained 
the observation that rupture is more frequently met with in the deliv- 
ery of male than of female children, on account, no doubt, of the larger 
size of the head in the former. The influence of intra-uterine hydro- 
cephalus was first prominently pointed out by Sir James Simpson, 1 
who states that out of seventy-four cases of intra-uterine hydrocephalus 
the uterus ruptured in sixteen. In all such cases of disproportion, 
whether referable to the pelvis or foetus, rupture is produced in a two- 
fold manner — either by the excessive and fruitless uterine contractions, 
which are induced by the efforts of the organ to overcome the obstacle ; 
or by the compression of the uterine tissue between the presenting part 
and the bony pelvis, leading to inflammation, softening, and even 
gangrene. 

The proximate cause of rupture may be classed under two heads — 
mechanical injury and excessive uterine contraction. Under the former 
are placed those uncommon cases in which the uterus lacerates as the 
result of some injury in the latter months of pregnancy, such as blows, 
falls, and the like. Not so rare, unfortunately, are lacerations pro- 
duced by unskilled attempts at delivery on the part of the medical 
attendant, such as by the hand during turning, or by the blades of the 
forceps. Many such cases are on record, in which the accoucheur has 
used force and violence, rather than skill, in his attempts to overcome 
an obstacle. That such unhappy results of ignorance are not so un- 
common as they ought to be is proved by the figures of Jolly, who has 
collected seventy-one cases of rupture during podalic version, thirty- 
seven caused by the forceps, ten by the cephalotribe, and thirty during 
other operations the precise nature of which is not stated. 2 The modus 
operandi of protracted and ineffectual uterine contractions, as a proxi- 
mate cause of rupture, is sufficiently evident, and need not be dwelt on. 
It is necessary to allude, however, to the effect of ergot, incautiously 
administered, as a producing cause. There is abundant evidence that 
the injudicious exhibition of this drug has often been followed by 
laceration of the unduly stimulated uterine fibres. Thus, Trask, talk- 
ing of the subject, says that Meigs had seen three cases, and Bedford 
four, distinctly traceable to this cause. Jolly found that ergot had 
been administered largely in thirty-three cases in which rupture 
occurred. 

Premonitory Symptoms. — Some have believed that the impending 
occurrence of rupture could frequently be ascertained by peculiar pre- 
monitory symptoms, such as excessive and acute crampy pains about 
the lower part of the abdomen, due to the compression of part of the 
uterine walls. These are far too indefinite to be relied on, and it is 
certain that the rupture generally takes place without any symptoms 
that would have afforded reasonable grounds for suspicion. 

General Symptoms. — The symptoms are often so distinct and 
alarming as to leave no doubt as to the nature of the case. Not infre- 

i Selected Obst. Works, p. 385. 2 Op. cit., p. 38. 



RUPTURE OP THE UTERUS. 456 

quently, however, especially if the laceration be partial, they are by 
do means so well marked, and the practitioner may be uncertain as to 
what has taken place. In the former class of cases a sudden excruci- 
ating pain is experienced in the abdomen, generally during the uterine 

contractions, accompanied by a feeling, on the pari of the patient, of 
something having given way. In some cases this has been accom- 
panied by an audible sound, which lias been noticed by the bystanders. 
At the same time there is generally a considerable escape of blood from 
the vagina, and a prominent symptom is the sudden cessation of the 
previously strong pains. Alarming general symptoms soon develop, 
partly due to shock, partly to loss of blood, both external and internal. 
The face exhibits the greatest suffering, the skin becomes deadly cold 
and covered with a clammy sweat, and fainting, collapse, rapid feeble 
pulse, hurried breathing, vomiting, and all the usual signs of extreme 
exhaustion quickly follow. 

Abdominal palpation and vaginal examination both afford character- 
istic indications in well-marked cases. If the child, as often happens, 
has escaped entirely, or in great part, into the abdominal cavity, it 
may be readily felt through the abdominal walls ; while in the former 
case, the partially contracted uterus may be found separate from it in 
the form of a globular tumor, resembling the uterus after delivery. 
Per vaginam it may generally be ascertained that the presenting part 
has suddenly receded, and can no longer be made out, or some other 
part of the foetus may be found in its place. If the rupture be exten- 
sive, it may be appreciable on vaginal examination, and, sometimes, 
a loop of intestine may be found protruding through the tear. Other 
occasional signs have been recorded, such as an emphysematous state 
of the lower part of the abdomen, resulting from the entrance of air 
into the cellular tissue ; or the formation of a sanguineous tumor in 
the hypogastrium or vagina. These are too uncommon and too vague 
to be of much diagnostic value. 

Unfortunately, the symptoms are by no means always so distinct, 
and cases occur in which most of the reliable indications, such as the 
sudden cessation of the pains, the external hemorrhage, and the retro- 
cession of the presenting part, may be absent. In some cases, indeed, 
the symptoms have been so obscure that the real nature of the case has 
only been detected after death. It is rarely, however, that the occur- 
rence of shock and prostration is not sufficiently distinct to arouse 
suspicion, even in the absence of the usual marked signs. In not a 
few eases distinct and regular contractions have gone on after lacera- 
tion, and the child has even been born in the usual way. Of course, 
in such a case mistake is very possible. So curious a circumstance is 
difficult of explanation. The most probable way of accounting for it 
is, that the laceration has not implicated the fundus of the uterus, 
which contracted sufficiently energetically to expel the fetus. Hence 
it will be seen that the symptoms are occasionally obscure, and the 
practitioner must be careful not to overlook the occurrence of so 
serious an accident because of the absence of the usual and character- 
istic symptoms. 

Prognosis. — The prognosis is necessarily of the gravest possible 



456 LABOR. 

character, but modern views as to treatment perhaps justify us in say- 
ing that it is not so absolutely hopeless as has been generally taught 
in our obstetric works. When we reflect on what has occurred — the 
profound nervous shock ; the profuse hemorrhage, both external and, 
especially, into the peritoneal cavity, where the blood coagulates and 
forms a foreign body ; the passage of the uterine contents into the 
abdomen, with the inevitable result of inflammation and its conse- 
quences, if the patient survive the primary shock — the enormous 
fatality need cause no surprise. Jolly has found that out of 580 cases 
100 recovered — that is, in the proportion of 1 out of 6. This is a far 
more favorable result than we are generally led to anticipate ; and as 
many of the recoveries happened in apparently the most desperate and 
unfavorable cases, we should learn the lesson that we need not abandon 
all hope, and should at least endeavor to rescue the patient from the 
terrible dangers to which she is exposed. 

As regards the child, the prognosis is almost necessarily fatal ; and, 
indeed, the cessation of the foetal heart-sounds has been pointed out by 
McClintock as a sign of rupture in doubtful cases. The shock, the 
profuse hemorrhage, and the time that must necessarily elapse before 
the delivery of the child, are of themselves quite sufficient to explain 
the fact that the foetus is almost always dead. 

Treatment. — From what has been said of the impossibility of fore- 
telling the occurrence of rupture, it must follow that no reliable 
prophylactic treatment can be adopted beyond that which is a matter 
of general obstetric principle, viz., timely interference when the uterine 
contractions seem incapable of overcoming an obstacle to delivery, 
either on the part of the pelvis or foetus. 

After rupture the main indications are to effect the removal of the 
child and the placenta, to rally the patient from the effects of the 
shock, aud, if she survive so long, to combat the subsequent inflamma- 
tion and its consequences. By far the most important point to decide 
is the best means to be adopted for the removal of the child ; for it is 
admitted by all that the hopeless expectancy that was recommended 
by the older accoucheurs, or, in other words, allowing the patient to die 
without making any effort to save her, is quite inadmissible. If the 
foetus be entirely within the uterine cavity, no doubt the proper course 
to pursue is to deliver at once per vias^naturales, either by turning, by 
forceps, or by cephalotripsy. If any part other than the head present, 
turning will be best, great care beiug taken to avoid further increase 
of the laceration. If the head be in the cavity or at the brim of the 
pelvis, and within easy reach of the forceps, it may be cautiously 
applied, the child being steadied by abdominal pressure so as to 
facilitate its application. If there be, as is often the case, some slight 
amount of pelvic contraction, it may be preferable to perforate and 
apply the cephalotribe, so as to avoid any forcible attempts at extrac- 
tion, which might unduly exhaust the already prostrate patient and 
turn the scale against her. This will be the more allowable, since the 
child is, as we have seen, almost always dead, and we might readily 
ascertain if it be so by auscultation. 

After delivery extreme care must be taken in removing the placenta, 



RUPTURE OF THE UTERUS. 457 

and for this it will be necessary to introduce the hand. The placenta. 
will generally be in the uterus, for if the rent be not Large enough for 
the child to pass through, it maybe inferred that the placenta will not 
have done so either. 1 1" it has escaped from the uterus, very gentle 

traction on the cord may bring it within reach of the hand, and SO the 
passage of the hand through the tear to search for it will be avoided; 

but, in all cases of this kind, there must have been a very considerable 

escape of blood into the uterine cavity, and abdominal section will 
probably give the patient a better chance of recovery. 

There can be but little doubt that, in the cases indicated, such is the 
proper treatment, and that which affords the mother the best chance. 
Unfortunately, the cases in which the child remains entirely in utero 
are comparatively uncommon, and generally it will have escaped into 
the abdomen, along with much extravasated blood. The usual plan 
of treatment recommended under such circumstances is to pass the 
hand through the fissure (some have even recommended that it should 
be enlarged by incision if necessary), to seize the feet of the foetus, to 
drag it back through the torn uterus, and then to reintroduce the hand 
to search for aud remove the placenta. Imagine what occurs during 
the process. The hand gropes blindly among the abdominal viscera, 
the forcible dragging back of the foetus necessarily tears the uterus 
more and more, and, above all, the extravasated blood remains as a 
foreign body in the peritoneal cavity, and necessarily gives rise to the 
most serious consequences. It is surely hardly a matter of surprise 
that there is scarcely a single case on record of recovery after this 
procedure. 

Of late years a strong feeling has existed that, whenever the child 
has entirely, or in great part escaped into the abdominal cavity, the 
operation of coeliotomy affords the mother a far better chance of 
recovery ; and it has now been performed in many cases with the most 
encouraging results. It is easy to see why the prospects of success 
are greater. The uterus being already torn, and the peritoneum 
opened, the only additional danger is the incision of the abdominal 
parietes, which gives us the opportunity of washing out the peritoneal 
cavity and of removing all the extravasated blood, the retention of 
which so seriously adds to the dangers of the case, as well as closing the 
rents in the uterus, if it be within reach, with both deep and superficial 
sutures, as in the improved Cesarean section. Another advantage is 
that, if the patient be excessively prostrate, the operation may be 
delayed until she has somewhat rallied from the effects of the shock, 
whereas delivery by the feet is generally resorted to as soon as the 
rupture is recognized, and when the patient is in the worst possible 
condition for interference of any kind. 

Jolly has carefully tabulated the results of the various methods of 
treatment, and, making every allowance for the unavoidable errors of 
statistics, it seems beyond all question that the results of coeliotomy 
are so greatly superior to those of other plans that I think its adoption 
may be fairly laid down as a rule whenever the foetus is no longer 
wholly within the uterine cavity. 



458 



LABOR. 



Comparative Results of Various Methods of Treatment after 
Rupture of Uterus. 



Treatment. 



Expectation 

Extraction per vias nalurales 

Coeliotoniy 



No. of i 



144 

382 



Deaths. 


Recoveries. 


142 


2 


310 


72 


12 


26 



Per cent, of 
recoveries. 



1.45 
19 

68.4 



Of course, this table will not justify the conclusion that 68 per cent, 
of the cases of ruptured uterus in which coeliotoniy is performed will 
recover ; but it may fairly be taken as proving that the chances of 
recovery are at least three or four times as great as when the more 
usual practice is adopted. 1 

Porro's operation has been suggested instead of simple coeliotoniy. 
In seven cases tabulated by Godson, in which this operation was per- 
formed after rapture of the uterus, the mothers all died; 2 but this 
does not prove that this plan, which adds little to the dangers of the 
case, should not be adopted. It has, at least, the advantage of effect- 
ually preventing the possibility of the recurrence of rupture in a future 
pregnancy. 

[Supra- vaginal hysterectomy, unless preceded by a true Cesarean 
section, has no right or title to the name of " Porro," any more than 
the same operation for a uterine fibroma has. The method has two 
very serious objections to its performance: 1, it is generally fatal in 
its results ; 2, we have no right to nnsex a well- formed woman because 
she has had the misfortune to rupture her uterus, when a better result 
may be attained by carefully suturing the laceration. — Ed.] 

Lacerations of the cervix are of very common occurrence. Occa- 
sionally, after delivery, they may cause hemorrhage, when the uterus 
itself is firmly contracted; or secondary hemorrhage during the puer- 
peral month. As a rule they are not recognized, and it is only of late 
years, and chiefly owing to the labors of Emmet, that their important 
influence in producing various chronic forms of uterine disease has 
been realized. In the large majority of cases the lacerations are lateral, 
either on one or both sides of the cervix. If they give rise to 
hemorrhage, the local application of styptics is probably the best re- 
source. Whether it is advisable to treat severe forms by the imme- 
diate application of silver sutures, as recommended by Pallen, 3 is a 
subject as yet too little understood to justify the expression of an 
opinion. 

1 American Puerperal Cceliotomies. — After a search of several years, I have thus far collected forty 
cases in the United States, with twenty-one women and two children saved. One mother and 
child were saved by an immediate operation with a pocket-knife, in 1869. I presume that a 
general record of American operations published and unpublished would show a saving of about 
50 per cent., which is much lower than that claimed by Trask and Jolly, collected from published 
reports, and less than I thought myself a year ago. Take Trask's foreign cases, twenty, and our 
own forty, and we have native and foreign, sixty, with thirty-seven recoveries and twenty-three 
deaths. I look upon our own statistics as much more reliable, because many of the unpublished 
cases were searched out by correspondence. — Harris's note to last American edition. 

2 A successful case has recently been reported by Professor Slavjansky, of St. Petersburg. 

3 Transactions of the Intern. Med. Congress, vol. iv. 



RUPTURE OF THE UTERUS. |.V.) 

It is, perhaps, needless to Bay that the operation must be performed 
with the same minute care thai has raised ovariotomy to its present 
pitch of perfection, and that special attention must be paid to the wash- 
ing out of the peritoneum, the removal of foreign matter-, and to the 
careful suturing of the uterine wound, whenever thai is practicable. 

Recapitulation. — To recapitulate, I think what has been said justi- 
fies the following rules of treatment after rupture: 

1. H the head or presenting part be above the brim, and the foetus 
still in utero — forceps, turning, or cephalotripsy according to circum- 
stances. 

2. If the head be in the pelvic cavity — forceps or cephalotripsy. 

3. If the foetus have wholly, or in great part, escaped into the 
abdominal cavity — coeliotomy. 

As to the subsequent treatment, little need be said, since in this 
we must be guided by general principles. The chief indication will 
be to remove shock, to rally the patient by stimulants, etc., and to 
combat secondary results by opiates and other appropriate remedies. 

Drainage has been recommended in cases in which coeliotomy has 
not been resorted to, and the results are said to have been good. 
Mann 1 advises that a large piece of drainage-tube should be bent in 
the middle, at which point a free opening should be made. This bent 
portion is passed for about half an inch through the laceration, the 
free ends are fastened together beyond the vulva, and covered with an 
antiseptic dressing. After forty-eight hours the wound should be 
regularly irrigated with 2 per cent, solution of carbolic acid. 

Lacerations of the vagina occasionally take place, and in the 
great majority of cases they are produced by instruments, either from 
a want of care in their introduction, or from undue stretching of the 
vaginal walls during extraction with the forceps. Slight vaginal 
lacerations are probably much more common after forceps delivery 
than is generally believed to be the case. As a rule, they are produc- 
tive of no permanent injury, although it must not be forgotten that 
every breach of continuity increases the risk of subsequent septic 
absorption. When the laceration is sufficiently deep to tear through 
the recto- vaginal septum or the anterior vaginal wall, the passage of 
the urine or feces is apt to prevent its edges uniting ; then that most 
distressing condition, recto-vaginal or vesico-vaginal fistula, is estab- 
lished. 

It must not be supposed that fistula? are often the result of injury 
during operative interference. That is a common but very erroneous 
opinion both among the profession and the public. In the vast 
majority of cases the fistulous opening is the consequence of a slough 
resulting from inflammation, produced by long-continued pressure of 
the vaginal walls between the child's head and the bony pelvis, in 
cases in which the second stage has been allowed to go on too long. 
In most of these cases instruments were doubtless eventually used, 
and thev get the blame of the accident ; whereas the fault lay, not in 
their being employed, but rather in their not having been used soon 

i Centralblatt f. Gyniik., 1881, Bd. v. S. 377. 



460 LABOR. 

enough to' prevent the contusion and inflammation which ended in 
slouching. 

When vesico-vaginal fistula? are the result of lacerations during 
labor, the urine must escape at once ; but this is rarely the case. In 
the large majority of cases the urine does not pass per vaginam until 
more than a week after delivery, showing that a lapse of time is neces- 
sary for inflammatory action to lead to sloughing. In order to throw 
some light on these points, on which very erroneous views have been 
held, I have carefully examined the histories, from various sources, of 
63 cases of vesico-vaginal fistula. 

Statistical Facts. — 1st. In 20 no instruments were employed. Of 
these, there were in labor 

Under 24 hours 2 

From 24 to 48 " 8 1 

" 40 to 70 " 2 

" TOtoSf " 7 

" 80 hours and upward 1 



Therefore out of these 20 cases one-half were certainly more than 
forty-eight hours in labor, and 6 of the remaining 10 were probably 
so also. In only one of them is the urine stated to have escaped per 
vcginam immediately after delivery. In 7 it is said to have done so 
within a week, and in the remainder after the seventh day. 

2d. In 34 cases instruments were used, but there is no evidence of 
their having produced the accident. Of these there were in labor 



Under 24 hours 2 

From 24 to 48 " 8 

" 48 to 72 " 10 

" 72 hours and upward 14 

34 

The nrine escaped within twenty-four hours in 2 cases only, within a 
week in 16, and after the seventh day in 15. 

So that here again we have the history of unduly protracted de- 
livery, 24 out of the 34 having been certainly more than forty-eight 
hours in labor. 

3d. In 9 cases the histories show that the production of the fistula 
may fairly be ascribed to the unskilled use of instruments. Of these 
there were in labor 

Under 24 hours 7 

From 24 to 48 " 1 

" 48 to 72 " 1 



The urine escaped at once in 7 cases, and in the remaining 2 after the 
seventh day. 

These statistics seem to me to prove, in the clearest manner, that, 
in the large majority of cases, this unhappy accident may be directly 
traced to the bad practice of allowing labor to drag on many hours in 
the second stage without assistance, and not to premature instrumental 
interference. This question has recently been elaborately studied by 

1 But of these in 7 no precise time is stated. Six of them are marked very tedious, therefore they 
probably exceeded the limit. 



RUPTURE OF THE UTERUS. 461 

Emmet, who gives numerous statistical tables which fully corroborate 
these views. His conclusion, the result of much practical experience 
of vesico-vaginal fistulse, is worthy of being quoted : " I do not hesi- 
tate," he says, "to make the statement that I have never met with a 
case of vesico-vaginal fistula which, without doubt, could he shown to 
have resulted from instrumental delivery. On the contrary, the entire 
weight of evidence is conclusive in showing that the injury is a conse- 
quence of delay in delivery." 1 

Treatment. — As to the treatment of vaginal laceration, little can he 
said. In the slighter cases antiseptic vaginal injections will be useful 
to lessen the risk of septic absorption; and the graver, when vesico- 
vaginal or recto-vaginal fistulse have actually formed, are not within 
the domain of the obstetrician, but must be treated surgically at some 
future date. 

[The Rational Treatment of Rupture of the Uterus. — The three 
rules given on page 459 are those found in obstetrical works of 
high authority, but are not based upon the teachings of abdominal 
surgery as shown by the results of operations recorded within a few 
years. Reasoning from analogy and the fearful mortality of cases 
delivered per vias naturales after uterine rupture, we are forced to the 
conclusion that something more is needed than the delivery of the 
woman and the removal of the placenta if we hope to reduce the pro- 
portion of deaths, which is very great except after coeliotomy — a method 
of delivery capable of saving nearly 50 per cent. There is no objection 
to delivering the foetus by the natural channel, provided it can be 
readily done ; but we have very little reason to anticipate a favorable 
result if we rest our efforts here. Children entirely escaped into the 
abdominal cavity have been drawn back through the rent and delivered 
by the vagina, and the women have recovered, In one well-authen- 
ticated case the woman was thus saved in our own country on four 
occasions. But we are not to expect such results, as a fatal issue is far 
more frequent than a recovery under such circumstances. Our object 
should be to save the life of the mother and, if at all possible, that of 
the foetus, and all our efforts should be directed to this end. We may 
console ourselves with having delivered the woman prior to her death, 
but to prevent this fatal issue should be our chief aim. The general 
impression among ovariotomists is, that blood is not an innocent fluid 
in the abdominal cavity ; and the remarkable results of the operations 
of Dr. Keith, of London, formerly of Edinburgh, are attributed to the 
care he exercised in preventing the secondary escape of blood into the 
abdominal cavity. The late Dr. Ludwig Winckel, of MuHheim, Ger- 
many, who performed the Caesarean operation fourteen times and 
coeliotomy after rupture of the uterus four times, was of the impression 
that the liquor amnii was innocuous if only a short time in contact 
with the peritoneum ; and the same may be said of blood, ovarian fluid, 
parovarian fluid, and, to some degree, also of urine. Rupture of the 
bladder is now cured by sewing up the rent and carefully cleansing the 
abdominal cavity of blood and urine. But these fluids are all capable 

1 The Principles and Practice of Gynecology, p. 669. 



462 LABOK. 

of setting up peritonitis, and blood by its decomposition is particularly 
apt to give rise to septic poisoning ; then why let it remain in the 
abdominal cavity in cases of ruptured uterus ? If it is important to 
cleanse this cavity from blood and ovarian fluid in ovariotomy, and 
from blood and amniotic fluid after the Cesarean section, then why 
should we be content with delivering the foetus in cases of rupture of 
the uterus, when we know that the peritoneal cavity still contains a 
compound fluid which may destroy the woman if not removed and the 
parts cleansed ? We have also an additional risk in the fact that the 
uterine rapture may gape and allow the lochia to escape into the peri- 
toneal cavity, thus providing another element for septic poisoning. I 
am, then, fully persuaded that in all cases of rupture, where it is evi- 
dent that blood and liquor amnii have escaped into the abdominal 
cavity, we ought to open the abdomen, cleanse out the cavity, and close 
up the rent by deep-seated and superficial sutures of carbolized pure 
silk. In cervico-vaginal rupture the closure of the rent may not be so 
important in the sense of safety to the woman, as there is generally a 
natural drainage into the vagina ; neither is coeliotomy itself so im- 
peratively demanded as in cases where the fundus or body of the uterus 
is rent. But it becomes important to close the torn cervix in view of 
future trouble from ectropium and erosion. As in the Cesarean oper- 
ation, promptness of action is all-important if we hope to save the 
patient. I know that these views upon the treatment of ruptured 
uterus are in advance of those held by British obstetrical writers, but 
they are certainly logical deductions from the experience of such 
operators as Dr. Keith, Mr. Lawson Tait, and others, and from the 
well-known results of promptly performed coeliotomies in rupture acci- 
dents in the United States. The removal of the uterus after rupture 
has as yet only added to the risk, and I do not believe we are justified 
in resorting to it where there is no pelvic obstruction. — Ed.] 



CHAPTEE XVII 

INVERSION OF THE UTERUS. 

Inversion of the uterus shortly after the birth of the child is one 
of the most formidable accidents of parturition, leading to symptoms 
of the greatest urgency, not rarely proving fatal, and requiring prompt 
and skilful treatment. Hence it has obtained an unusual amount of 
attention, and there are few obstetric subjects which have been more 
carefully studied. 

Fortunately, the accident is of great rarity. It was only observed 
once in upward of 190,800 deliveries at the Rotunda Hospital since 
its foundation in 1745 ; and many practitioners have conducted large 



INVERSION OF THE UTERUS 



163 



Fig. 155. 



midwifery practices for a lifetime without ever having w itnessed a case. 
It is none the less needful, however, thai we should be thoroughly 
acquainted with its natural history, and with the besl mean- of dealing 
with the emergency when it arises. 

Acute and Chronic Forms. — Inversion of the uterus may be met 
with in the acute or chronic form ; that is to say, it may conic under 
observation either immediately or shortly after its occurrence, or ool 
until after a considerable lapse of time, when the involution following 
pregnancy has been completed. The latter falls more properly under 
the province of the gynecologist, and involves the consideration of 
many points that would be out of place in a work on obstetrics. Here, 
therefore, the acute form alone 1 is considered. 

Description. — Inversion consists essentially in the enlarged and 
empty uterus being turned inside out, either partially or entirely; and 
this may occur in various degrees, three of which are usually described, 
and are practically useful to bear in mind. In the first and slightest 
degree there is merely a eup-shaped depression of the fundus (Fig. 
155); in the second the depression is 
greater, so that the inverted portion forms 
an introsusception, as it were, and pro- 
jects downward through the os in the form 
of a round ball, not unlike the body of a 
polypus, for which, indeed, a careless ob- 
server might mistake it ; and, thirdly, 
there is the complete variety, in which 
the whole organ is turned inside out and 
may even project beyond the vulva. 

The symptoms are generally very 
characteristic, although, when the amount 
of inversion is small, they may entirely 
escape observation. They are chiefly those 
of profound nervous shock, viz., fainting, 
small, rapid, and feeble pulse, possibly 
convulsions and vomiting, and a cold, 
clammy skin. Occasionally severe ab- 
dominal pain and bearing down are felt. 
Hemorrhage is a frequent accompani- 
ment, sometimes to a very alarming ex- 
tent, especially if the placenta be partially 
or entirely detached. The loss of blood 

depends to a great extent on the condition of the uterine parietes. If 
there be much contraction on the part that is not inverted, the intro- 
suseepted part may be sufficiently compressed to prevent any great 
loss. If the entire organ be in a state of relaxation the loss may be 
excessive. 

The occurrence of such symptoms shortly after delivery would of 
necessity lead to an accurate examination, when the nature of the case 
may be at once ascertained. On passing the finger into the vagina we 
either find the entire uterus forming a globular mass — to which the 
placenta is often attached — or, if the inversion be incomplete, the 




Partial inversion of the fundus. 
(From a preparation in the Museum 
of Guy's Hospital.) 



464 LABOR. 

vagina is occupied by a firm, round, and tender swelling, which can 
be traced upward through the os uteri. The hand placed on the 
abdomen will detect the absence of the round ball of the contracted 
uterus ; the bimanual examination may even enable us to feel the cup- 
shaped depression at the site of inversion. 

Differential Diagnosis. — "When such signs are observed immedi- 
ately after delivery mistake is hardly possible. Xumerous instances, 
however, are recorded in which the existence of inversion was not 
immediately detected, and the tumor formed by it only observed after 
the lapse of several days, or even longer, when the general symptoms 
led to vaginal examination. It is probable that, in such cases, a 
partial inversion had taken place shortly after delivery, which, as time 
elapsed, became gradually converted into the more complete variety. 
In a case of this kind, as in a chronic inversion, some care is necessary 
to distinguish the inversion from a uterine polypus, which it closely 
resembles. The cautious insertion of the sound will render the diag- 
nosis certain, since its passage is soon arrested in inversion ; while, if 
the tumor be polypoid, it readily passes in as far as the fundus. 

The mechanism by which inversion is produced is well worthy 
of study, and has given rise to much difference of opinion. 

A very general theory is that it is caused, in many cases, by mis- 
management of the third stage of labor, either by traction on the cord, 
the placenta being still adherent, or by improperly applied pressure on 
the fundus ; the result of both these errors being a cup-shaped depres- 
sion of the fundus, which is subsequently converted into a more com- 
plete variety of inversion. That such causes may suffice to start the 
inversion cannot be doubted, but it is probable that their frequency 
has been much exaggerated. Still, there are numerous recorded cases 
in which the commencement of the inversion can be traced to them. 
Improperly applied pressure (as when the whole body of the uterus is 
not grasped in the hollow of the hand, but when a monthly nurse, or 
other uninstructed person, presses on the lower part of the abdomen, 
so as simply to push down the uterus en masse) is often mentioned in 
histories of the accident. Thus, in the Edinburgh Medical Journal for 
June, 1848, a case is related in which the patient would not have a 
medical man, but was attended by a midwife, who, after the birth of 
the child, pulled on the cord, while the patient herself clasped her 
hands and pushed down her abdomen, at the same time straining 
forcibly, when the uterus became inverted and the patient died of 
hemorrhage before assistance could be procured. Here both of the 
mechanical causes alluded to were in operation. In several cases it is 
mentioned that the accident occurred while the nurse was compressing 
the abdomen. That the accident is practically impossible when firm 
and equable contraction has taken place cannot be questioned. Hence 
it is of paramount importance that the practitioner should himself 
carefully attend to the conduct of the third stage of labor. 

In a large proportion of cases no mechanical causes can be traced, 
and the occurrence of spontaneous inversion must be admitted. There 
are various theories held as to how this occurs. Partial and irregular 
contraction of the uterus is generally admitted to be an important 



INVERSION OF THE UTERUS. 



465 



factor in its production ; but it is still a matter of dispute whether the 
inversion is produced mainly by an active contraction of the fundus 
and body of the uterus, the Lower portion and cervix being in a state 
of relaxation ; or whether the precise reverse of this exists, the fundus 
being relaxed and in a state of quasi-paralysis, while the cervix and 
lower portion of the uterus are irregularly contracted. The former is 
the view maintained by Radford and Tyler Smith, while the latter is 
upheld by Matthews Duncan. 

There are good clinical reasons for believing that Duncan's view 
more nearly corresponds with the true facts of the case; for, if the 
fundus and body of the uterus he really in a state of active contraction, 
while the cervix is relaxed, we have, as Duncan points out, the very 
condition which is normal and desirable after delivery, and that which 
we do our best to produce. If, however, the opposite condition exists, 
and the fundus be relaxed, while the lower portion is spasmodically 
contracted, a state exists closely allied to the so-called hour-glass con- 
traction. Supposing now any cause produces a partial depression of 
the fundus, it is easy to understand how it may be grasped by the 
contracted portion, and carried more and more down, in the manner 
of an introsusception, until complete inversion results. That such 
partial paralysis of the uterine Avails often exists, especially about the 
placental site, was long ago pointed out by Kokitansky and other 
pathologists. This theory supposes the original partial depression and 
relaxation of the fundus. How this is 
often produced by mismanagement of the 
third stage has already been pointed out ; 
but even in the absence of such causes, it 
may result from strong bearing-down efforts 
on the part of the patient ; or, as Duncan 
holds, from the absence of the retentive 
power of the abdomen. Indeed, the in- 
compatibility of an actively contracted state 
of the fundus with the partial depression 
Avhich is essential, according to both views, 
for the production of inversion, is the 
strongest argument in favor of Duncan's 
theory. 

A totally different view has more recently 
been sustained by Dr. Taylor, of Xew York, 
who maintains that "spontaneous active in- 
version of the uterus rests upon prolonged 
natural and energetic action of the body 
and fundus; the cervix, the lower part, 
yielding first, is thus rolled out, or everted 
or doubled up, as there is no obstruction from the contractility of the 
cervix, which is at rest or functionally paralyzed • the body is gradually, 
sometimes instantaneously, forced lower and lower, or inverted." 1 
That partial inversion may commence at the cervix was pointed out 



Fig. 156. 




Illustrating the commencement 
of inversion at the cervix. (After 
Duncan.) 



New York Med. Journ., 1S72, vol. xv. p. 449. 
30 



466 LABOR. 

by Duncan in his paper, who depicts it in the accompanying diagram 
(Fig. 156), and states it to be of not unfrequent occurrence. It is not 
impossible that occasionally such a state of things should be carried on 
to complete inversion. But there are serious objections to the accept- 
ance of Dr. Taylor's view that such is the principal cause of inversion, 
since the process above described would be of necessity a slow and 
long-continued one, whereas nothing is more certain than that inversion 
is generally sudden and accompanied by acute symptoms of shock, and 
is often attended by severe hemorrhage, which could not occur when 
such excessive contraction was taking place. 

The treatment of inversion consists in restoring the organ to its 
natural condition as soon as possible. Every moment's delay only 
serves to render restoration more difficult, as the inverted portion 
becomes swollen and strangulated ; whereas if the attempt at reposition 
be made immediately, there is generally comparatively little difficulty 
in effecting it. Therefore, it is of the utmost importance that no time 
should be lost, and that we should not overlook a partial or incom- 
plete inversion. Hence the occurrence of any unusual shock, pain, or 
hemorrhage after delivery, without any readily ascertained cause, 
should always lead to a careful vaginal examination. A want of 
attention to this rule has too often resulted in the existence of partial 
inversion beino; overlooked until its reduction was found to be difficult 
or impossible. 

In attempting to reduce a recent inversion, the inverted portion of 
the uterus should be grasped in the hollow of the hand and pushed 
gently and firmly upward into its natural position, great care being 
taken to apply the pressure in the proper axis of the pelvis, and to use 
counter-pressure, by the left hand, on the abdominal walls. Barnes 
lays stress on the importance of directing the pressure toward one side 
so as to avoid the promontory of the sacrum. The common plan of 
endeavoring to push back the fundus first has been well shown by 
McClintock 1 to have the disadvantage of increasing the bulk of the 
mass that has to be reduced, and he advises that, while the fundus is 
lessened in size by compression, we should, at the same time, endeavor 
to push up first the part that was less inverted — that is to say, the por- 
tion nearest the os uteri. Should this be found impossible, some assist- 
ance may be derived from the manoeuvre, recommended by Merriman 
and others, of first endeavoring to push up one side or wall of the 
uterus, and then the other, alternating the upward pressure from one 
side to the other as we advance. It often happens, as the hand is thus 
applied, that the uterus somewhat suddenly replaces itself, sometimes 
with an audible noise, much as an India-rubber bottle would do under 
similar circumstances. "When reposition has taken place, the hand 
should be kept for some time in the uterine cavity to excite tonic con- 
traction ; or a stream of hot water at 110° F. may be injected, and if 
that fails, a weak solution of perch loride of iron, so as to cause tonic 
contraction of the uterus and thus prevent a recurrence of the accident. 

It is hardly necessary to point out hoAV much these manoeuvres will 

1 Diseases of Women, p. 79. 



INVERSION OF THE UTERUS. 467 

be facilitated by placing the patient folly under the influence of an 
anaesthetic. 

There has been much difference of opinion as to the management of 
the placenta in cases in which it is still attached when Inversion occurs. 
Should we remove it before attempting reposition, or should we first 
endeavor to rein vert the organ and subsequently remove the placenta? 
The removal of the placenta certainly much diminishes tin; bulk of 
the inverted portion, and, therefore, renders reposition easier. On the 
other hand, it' there he much hemorrhage, as is so frequently the case, 
the removal of the placenta may materially increase the loss of blood. 
For this reason most authorities recommend that an endeavor should 
be made at a reduction before peeling off the after-birth. But if any 
delay or difficulty be experienced from the increased bulk, no time 
should be lost, and it is in every May better to remove the placenta 
and endeavor to reinvert the organ as soon as possible. 

Supposing we met with a case in which the existence of inversion 
has been overlooked for days, or even for a week or two, the same 
procedure must be adopted ; but the difficulties are much greater, and 
the longer the delay the greater they are likely to be. Even now, 
however, a well-conducted attempt at taxis is likely to succeed. Should 
it fail, we must endeavor to overcome the difficulty by continuous 
pressure applied by means of caoutchouc bags distended with water 
and left in the vagina. It is rarely that this will fail in a compara- 
tively recent case, and such only are now under consideration. It is 
likely that by pressure applied in this way for twenty- four or forty- 
eight hours, and then followed by taxis, any case detected before the 
involution of the uterus is completed may be successfully treated. 

[Spontaneous Reposition of the Inverted Uterus. — After all 
attempts have failed to replace an inverted uterus already too much 
contracted to yield to the pressure employed, Kature sometimes accom- 
plishes the work herself, as proved beyond question from quite a 
number of Avell-established cases, several of which belong to our own 
country. A few years ago I saw one of the most remarkable on record. 
A woman of twenty-nine, mother of three children, miscarried at six 
and a half months from lifting. From the time of her delivery she 
was subject to weepings of blood, and at times to more or less severe 
hemorrhages, one of the last of which nearly proved fatal. This con- 
dition of disease had lasted three years, when Dr. Walter F. Atlee 
was called in to relieve her in her worst hemorrhagic attack, and found 
her uterus inverted, and a nodular growth upon the fundus which 
gave out an offensive odor. Thinking the disease possibly malignant, 
and believing, in any event, that to save the woman lie would be 
obliged to remove the uterus, he called a consultation and prepared for 
the operation ; but when the patient was etherized, placed in the knee- 
elbow position, and Sims' speculum introduced, behold ! there was 
nothing to be seen in the vagina but a soft dilated cervix, the uterus 
having been replaced by atmospheric pressure, aided perhaps by trac- 
tion on the uterine attachments within. When explored, the uterus 
was found to be very soft and thin, and to contain some hard nodular 
masses, which on removal proved to be portions of an adherent 



468 LABOR. 

placenta. The hemorrhage ceased upon the reposition and cleaning- 
out of the uterus, and the patient made a good recovery. She has been 
again pregnant. 

This woman was anaemic to a marked degree, and her abdominal 
walls so thin that a finger in the uterus could readily be felt above the 
pubes. There is not the slightest doubt about the inversion, which 
was proved to exist a short time before the change of posture by Prof. 
Agnew, who made a finger in the rectum meet another above the 
pubes, and there was no fundus between them. 

.Two 1 cases are upon record where reposition was the result of falls, 
one at eight months and the other after as many years. Drs. Moehring, 
C. D. Meigs, H. L. Hodge, and Warrington, of this city, failed to 
replace a uterus, and the woman again became pregnant in about six 
years, aborting with a three months' foetus under the care of Dr. 
'Warrington. Dr. Meigs saw a second case with Dr. Levis, in which 
there was violent flooding followed by hemorrhages, which gradually 
declined. After her return from a journey West she became pregnant 
and bore a child. Dr. John L. Atlee, of Lancaster, failed to replace 
the uterus of a woman, but she recovered spontaneously and bore a 
child a year afterward. 2 Dr. Johnson F. Hatch, of Kent, Connecticut, 
reported a case in a letter to Dr. C. D. Meigs in which inversion 
occurred spontaneously fourteen or fifteen hours after labor. After 
being under the care of several physicians, she had, at the end of 
eighteen months, two severe hemorrhagic attacks, after which she im- 
proved, and finally, at the end of two years and nine months, bore a 
child of nine pounds and six ounces. 

In all cases spontaneous reposition appears to result from a soften- 
ing and thinning of the uterine walls as the result of anaemia brought 
on by hemorrhages. This was particularly noticed by Boivin and 
Duges in autopsies of women dying of repeated hemorrhages. — Ed.] 

C 1 See Daillez, Essai sur le Renversement de la Matrice, Paris, 1805, pp. 105-107.] 
1 2 Meigs' Obstetrics, Philadelphia, 1852, p. 608.J 



PART TY. 

OBSTETRIC OPERATIONS. 



CHAPTEK I. 

INDUCTION OF PREMATURE LABOR. 

History of the Operation. — The first of the obstetric operations 
we have to consider is the induction of premature labor, an operation 
which, like the use of forceps, was first suggested and practised in 
England, and the recognition of which, as a legitimate procedure, we 
also chiefly owe to the labor of English obstetricians, in spite of 
much opposition both at home and abroad. It is not known with cer- 
tainty to whom we owe the original suggestion, but we are told by 
Denman that in the year 1756 there was a consultation of the most 
eminent physicians at that time in London, to consider the advantages 
which might be expected from the operation. The proposal met with 
formal approval, and was shortly after carried into practice by Dr. 
Macaulay, the patient being the wife of a linendraper in the Strand. 
From that time it has nourished in Great Britain, the sphere of its 
application has been largely increased, and it has been the means of 
saving many mothers and children avIio would otherwise, in all prob- 
ability, have perished. On the Continent it was long before the opera- 
tion was sanctioned or practised. Although recommended by some of 
the most eminent German practitioners, it was not actually performed 
until the year 1804. In France the opposition was long-continued 
and bitter. Many of the leading teachers strongly denounced it, and 
the Academy of Medicine formally discountenanced it so late as the 
year 1827. The objections were chiefly based on religious grounds, 
but partly, no doubt, on mistaken notions as to the object proposed to 
be gained. Although frequently discussed, the operation was never 
actually carried into practice until the year 1831, when Stoltz per- 
formed it with success. Since that time opposition has greatly ceased, 
and it is now employed and highly recommended by the most distin- 
guished obstetricians of the French schools. 

Objects of the Operation. — In inducing premature labor, we pro- 
pose to avoid or lessen the risk to Avhich, in certain cases, the mother 
is exposed by delivery at term, or to save the life of the child which 
might otherwise be endangered. Hence the operation may be indi- 
cated either on account of the mother alone, or of the child alone, or, 
as not unfrequently happens, of both together. 

(469) 



470 OBSTETRIC OPERATIONS. 

In by far the largest number of cases the operation is performed on 
account of defective proportion between the child and the maternal 
passages, due to some abnormal condition on the part of the mother. 
This want of proportion may depend on the presence of tumors either 
of the uterus or growing from the pelvis. But most frequently it- 
arises from deformity of the pelvis (p. 415), and it is needless to repeat 
what has been said on that point. I shall therefore only briefly refer 
to a few more uncommon causes which occasionally necessitate its 
performance. 

One of these is an habitually large, or over-firmly ossified, foetal 
head. Should we meet with a case in which the labors are always 
extremely difficult, and the head apparently of unusual size, although 
there is no apparent want of space in the pelvis, the induction of labor 
would be perfectly justifiable, and in all probability would accomplish 
the desired object. In such cases the full period of delivery would 
require to be anticipated by a very short time. A week or a fortnight 
might make all the difference between a labor of extreme severity and 
one of comparative ease. 

There is a large class of cases in which the condition of the mother 
indicates the operation. Many of these have already been considered 
when treating of the diseases of pregnancy. Amongst them may be 
mentioned vomiting which has resisted all treatment, and which has 
produced a state of exhaustion threatening to prove fatal ; chorea, 
albuminuria, convulsions, or mania; excessive anasarca, ascites, or 
dyspnoea connected with disease of the heart, lungs, or liver, which 
may be, in a great measure, caused by the pressure of the enlarged 
uterus ; in fact, any condition or disease affecting the mother, provided 
only we are convinced that the termination of pregnancy would give 
the patient relief, and that its continuance would involve serious 
danger. It need hardly be pointed out that the induction of labor 
for any such causes involves great responsibility, and is decidedly 
open to abuse ; no practitioner would, therefore, be justified in resort- 
ing to it — especially if the child has not reached a viable age — 
without the most anxious consideration. ]STo general rules can be laid 
down. Each case must be treated on its own merits. It is obvious 
that the nearer the patient is to the full period, the greater will be the 
chance of the child surviving, and the less hesitation need then be felt 
in consulting the interest of the mother. 

In another class of cases the operation is indicated by circumstances 
affecting the life of the child alone. Of these the most common are 
those in which the child dies, in several successive pregnancies, before 
the termination of utero-gestation. This is generally the result of 
fatty, calcareous, or syphilitic degeneration of the placenta, which is 
thus rendered incapable of performing its functions. These changes 
in the placenta seldom commence until a comparatively advanced 
period of pregnancy ; so that if labor be somewhat hastened we may 
hope to enable the patient to give birth to a living and healthy child. 
The experience of the mother will indicate the period at which the 
death of the foetus has formerly taken place, as she would then have 
appreciated a difference in her sensations, a diminution in the vigor of 



INDUCTION OF PREMATURE LABOR. 471 

the foetal movements, a sense of weight and coldness, and similar 
signs. For some weeks before the time at which this change has been 
experienced, we should carefully auscultate the foetal heart from day 
to day, and in most cases the approach of danger will be indicated 
sufficiently soon to enable us to interfere with success, by tumultuous 
and irregular pulsations, or a failure in their strength and frequency. 
On the detection of these, or on the mother feeling that the move- 
ments of the child are becoming less strong, the operation should at 
once he performed. Simpson also induced premature labor with suc- 
cess in a patient who had twice 1 given birth to hydrocephalic children. 
Iu the third pregnancy, which he terminated before the natural period, 
the child was well formed and healthy. 

Some obstetricians have proposed to induce labor, with the view of 
saving the child, when the mother was suffering from mortal disease. 
This indication is however, so extremely doubtful, from a moral point 
of view r , that it cau hardly be considered as ever justifiable. 

Various Methods of Inducing" Labor. — The means adopted for 
the induction of labor are very numerous. Some of them act through 
the maternal circulation, as the administration of ergot and other 
oxytocics ; others by their power of exciting reflex action, or by in- 
terfering with the integrity of the ovum, or by a combination of 
both, as the vaginal douche, separation of the membranes from the 
uterine walls, puncture of the ovum, dilatation of the os, stimulating 
enemata, or irritation of the breasts. The former class are never 
employed in modern obstetric practice. Of the latter, some offer 
special advantages in particular cases, but none are equally adapted 
for all emergencies. Often a combination of more methods than one 
will be found most useful. I shall mention the various methods in 
use, and discuss briefly the relative advantages and disadvantages of 
each. 

Puncture of Membranes. — The evacuation of the liquor amnii by 
the puncture of the membranes was the first method practised, and 
was that recommended by Denman and all the earlier writers. It is 
the most certain which can be employed, as it never fails, sooner or 
later, to induce uterine contractions. There are, however, several dis- 
advantages connected with it which are sufficient to contra-indicate its 
use in the majority of cases. It is uncertain as regards the time taken 
in producing the desired effect, pains sometimes coming on within a 
few hours, but occasionally not until several days have elapsed. The 
contracting walls of the uterus press directly on the body of the child, 
which, being frail and immature, is less able to bear the pressure than 
at the full period of pregnancy. Hence it involves great risk to the 
foetus. Besides, the escape of the water does away with the fluid 
wedge so useful in dilating the os, and should version be necessary 
from malprescntation — a complication more likely to occur than in 
natural labor — the operation would have to be performed under very 
unfavorable conditions. These objections are sufficient to justify the 
ordinary opinion that this procedure should not be adopted unless 
other means have been tried and failed. Every now and then cases 
are met with in which it is extremlv difficult to arouse the uterus to 



472 OBSTETRIC OPERATIONS. 

action, and under such circumstances, in spite of its drawbacks, this 
method will be found to be very valuable. When the operation has 
to be performed before the child is viable — that is, before the seventh 
month — these objections do not hold, and then it is the simplest and 
readiest procedure we can adopt. Indeed, in producing early abortion, 
no other is practicable. The operation itself is most simple, requiring 
only a quill, stiletted catheter, or other suitable instrument, to be 
passed up to the os, carefully guarded by the fingers of the left hand 
previously introduced, and to be pressed against the membranes until 
perforation is accomplished. Meissner, of Leipzig, has proposed as a 
modification of this plan, that the membrane should be punctured 
obliquely, three or four inches above the os, so as to admit of a gradual 
and partial escape of the amniotic fluid, thus lessening the risk to the 
child from pressure by the uterus. For this purpose he employed a 
curved silver canula containing a small trocar, which can be pro- 
jected after introduction. The risk of injuring the uterus by such an 
instrument would be considerable, and we have other and better means 
at our command which render it unnecessary. AVhen we require to 
produce early abortion, it would be well not to attempt to puncture 
the membranes with a sharp-pointed instrument. The object can be 
effected with certainty and greater safety by passing an ordinary 
uterine sound through the os and turning it around once or twice. 

Administration of Oxytocics. — The administration of ergot of 
rye, either alone or combined with borax and cinnamon, has been 
sometimes resorted to. This practice has been principally advocated 
by Ramsbotham, who was in the habit of exhibitiug scruple doses of 
the powdered ergot every fourth hour until delivery took place. 
Sometimes he found that as many as thirty or forty doses were re- 
quired to effect the object ; occasionally labor commenced after a single 
dose. Finding that the infantile mortality was very great when this 
method was followed, he modified it and administered two or three 
doses only, and, if these proved insufficient, he punctured the mem- 
branes. There can be no doubt that ergot possesses the power of in- 
ducing uterine contractions. The risk to the child is, however, quite 
as great as when the membranes are punctured ; for not only is it 
subject to injurious pressure from the tumultuous and irregular con- 
tractions which the ergot produces, but the drug itself, when given in 
large doses, seems to exert a poisonous influence on the foetus. For 
these reasons ergot may properly be excluded from the available 
means of inducing labor. 

Methods Acting- Indirectly on the Uterus. — Various methods 
have been recommended which act indirectly on the uterus, the source 
of irritation being at a distance. Thus D'Outrepont used frequently 
repeated abdominal frictions and tight bandages. Scanzoni, remem- 
bering the intimate connection between the mammae and uterus, and 
the tendency which irritation of the former has to induce contraction 
of the latter, recommended the frequent application of cupping-glasses 
to the breasts. Radford and others have employed galvanism. 
Stimulating enemata have been employed. All these methods have 
occasionally proved successful, and, unlike the former plans we have 



INDUCTION OF PREMATURE LAROR 



473 



Fig. 157. 



mentioned, they are not attended by any special risk to the child. 
They are, how ever, much too uncertain to be relied on, besides being 
irksome both to the patient and practitioner. 

The artificial dilatation of the os uteri in imitation of its natural 
opening in labor was first practised by Kliige. He was in the habit 
of passing within the os a tent made of compressed sponge, and allow- 
ing it to dilate by imbibition of fluid. If labor was not provoked 
within twenty-four hours he removed it and introduced one of larger 
dimensions, changing it as often as was necessary until his object was 
accomplished. Although this operation seldom failed to induce labor, 
it had the disadvantage of occupying an indefinite time, and the irrita- 
tion produced was often painful and annoying. Dr. Keiller, of Edin- 
burgh, was the first to surest caoutchouc bas;s, distended bv air, as a 
means of dilating the os. This plan has been perfected by Dr. Robert 
Barnes in his well-known dilators, which are of great use in many 
cases in which artificial dilatation of the cervix is necessary. They 
consist of a series of India-rubber bags of various sizes with a tube 
attached (Fig. 157), through which water can be injected by an ordinary 
Higginson's syringe. They have a small pouch fixed externally, in 
which a sound can be placed, so as to facilitate their 
introduction. When distended with water the bags 
assume somewhat of a fiddle shape, bulging at both 
extremities, which insures their being retained within 
the os. When first introduced into practice as a 
means of inducing labor, it was thought that this 
method gave a complete control over the process, so 
that it could be concluded within a definite time at 
the will of the operator. The experience of those 
who have used it much has certainly not justified 
this anticipation. It is true that occasionally con- 
tractions supervene within a few hours after dilata- 
tion has been commenced ; but, on the other hand, 
the uterus often responds very imperfectly to this 
kind of stimulus, and the bags may be inserted for 
manv consecutive hours without the desired result 

,, P . i i -, . Barnes bag for dilat- 

supervening, the puncture oi the membranes being ing the cervix. 
eventually necessary in order to hasten the process. 
Indeed, my own experience would lead me to the conclusion that, as a 
means of evoking uterine contraction, cervical dilatation is very un- 
satisfactory. Dr. Barnes himself has evidently seen reason to modify 
his original views, for while he at first talked of the bags as enabling 
us to induce labor with certainty at a given time, he has since recom- 
mended that uterine action should be first provoked by other means, 
the dilators being subsequently used to accelerate the labor thus 
brought on. The bags thus employed find, as I believe, their most 
useful and a very valuable application ; but when used in this way 
they cannot be considered a means of originating uterine action. A 
subsidiary objection to the bags is the risk of displacing the presenting 
part. I have, for example, introduced them when the head was pre- 
senting, and, on their removal, found the shoulder lying over the os. 




474 



OBSTETRIC OPERATIONS. 



It is not difficult to understand Low the continuous pressure of a dis- 
tended bag in the internal os might easily push away the head, which 
is so readily movable so long as the membranes are unruptured. Still, 
if labor be in progress, and the os insufficiently dilated, the possibility 
of this occurrence is not a sufficient reason for not availing ourselves 
of the undoubtedly valuable assistance which the dilators are capable 



Fig. 158. 




Champetier de Ribes' dilator and introducing forceps. 

of giving. A modified form of dilator, invented by Champetier de 
Ribes, 1 has been highly spoken of and promises to be useful (Fig. 158). 
It differs from Barnes's instrument in being conical, in being made of 
inelastic waterproof silk, and in being much larger, so that when the 
expanded bag has passed through the cervical canal, the child can be 
quickly delivered. It is introduced by special forceps, and left until 

i Annal. de Gyn., 1888, p. 401. 



INDUCTION OF PREMATURE LABOR. 475 

it is expelled by the pains. The average time in which this happened 
in sixteen cases was eight hours. 

Separation of the Membranes. — Some processes for inducing 
labor act directly on the ovum by separating the membranes, to a 
greater or less extent, from the uterine walls. The first procedure of 
the kind was recommended by Dr. Hamilton, of Edinburgh, and con- 
sisted in the gradual separation of the membranes for one or two 
inches all round the lower segment of the uterus. To reach them the 
finger had to be gently insinuated into the interior of the os, which 
was gradually dilated to a sufficient extent by a series of successive 
operations, repeated at intervals of three or four hours. When this 
had been accomplished, the forefinger was inserted and swept round 
between the membranes and the uterus, but it was frequently found 
necessary to introduce the greater part of the hand to effect the object, 
and sometimes even this was not sufficient and a female catheter or 
other instrument had to be used for the purpose. The method was 
generally successful in bringing on labor, but it now and then failed, 
even in Dr. Hamilton's hands. It is certainly based on correct prin- 
ciples, but it is tedious and painful, both to the practitioner and the 
patient, and very uncertain in its time of action. For these reasons 
it has never been much practised. 

Vaginal and Uterine Douches. — In the year 1836, Kiwisch sug- 
gested a plan which, from its simplicity, has met with much approval. 
It consists in projecting, at intervals, a stream of warm or cold water 
against the os uteri. Its action is doubtless complex. Kiwisch him- 
self believed that relaxation of the soft parts, through the imbibition 
of water, was the determining cause of labor. Simpson found that 
the method failed unless the water mechanically separated the mem- 
branes from the uterine walls. Besides this effect it probably directly 
induces reflex action by distending the vagina and dilating the os. In 
using it, it has been customary to administer a douche twice daily, 
and more frequently if rapid effects be desired. The number required 
varies in different cases. The largest number Kiwisch found it neces- 
sary to use was seventeen, the smallest five. The average time that 
elapses before labor sets in is four days. Hence the method is obvi- 
ously useless when rapid delivery is required. 

Dr. Cohen, of Hamburg, introduced an important modification of 
the process, which has been considerably practised. It consists in 
passing a silver or gum-elastic catheter some inches within the os, 
between the membranes and the uterine walls, and injecting the fluid 
through it directly into the cavity of the uterus. He used creasote 
or tar water, and injected without stopping until the patient com- 
plained of a feeling of distention. Others have found the plan 
equally efficacious when they only employed a small quantity of plain 
water, such as seven or eight ounces. Professor Lazarewitch, of St. 
Petersburg, is a strong advocate of this method. He believes that 
uterine action is evoked much more rapidly and certainly if the water 
be injected near the fundus, and he has contrived an instrument for 
the purpose, with a long metallic nozzle. 

Dangers of these Plans. — So many fatal cases have followed these 



476 OBSTETKIC OPERATIONS. 

methods, that it cannot be doubted that, in spite of their certainty and 
simplicity, there is an element of risk in them that should not be 
overlooked. Many of these are recorded in Barnes's work, and he 
comes to the conclusion, which the facts unquestionably justify, that 
" the douche, whether vaginal or intra-uterine, ought to be absolutely 
condemned as a means of inducing labor." The precise reason of the 
danger is not very obvious. Sudden stretching of the uterine walls, 
producing shock, has been supposed to have caused it ; but in many 
of the fatal cases the symptoms have been rather those attending the 
passage of air into the veins, and it is easy to understand how air may 
have been introduced in this way into the large uterine sinuses. 

Simpson and Scanzoni have both tried with success the injection of 
carbonic acid gas into the vagina. Fatal results have, however, fol- 
lowed its employment, and Simpson expressed an opinion that the 
experiment should not be repeated. 

Simpson originally induced labor by passing the uterine sound 
within the os, and up toward the fundus, and, when it had been in- 
serted to a sufficient extent, moving it slightly from side to side. He 
was led to adopt this procedure in the belief that Ave might thus 
closely imitate the separation of the decidua, which occurs previous to 
labor at term. Uterine contractions were induced with certainty and 
ease, but it was found impossible to foretell what time might elapse 
between the commencement of labor and the operation, which had 
frequently to be performed more than once. He subsequently modi- 
fied this procedure by introducing a flexible male catheter, without a 
stilette, which he allowed to remain in the uterus until contractions 
were excited. This plan is much used in Germany, and is now that 
w T hich is also most frequently adopted in England. It is simple 
and very efficacious, pains coming on almost invariably within 
twenty-four hours after the catheter or bougie is introduced. A theo- 
retical objection is the possibility of the catheter separating a portion 
of the placenta and giving rise to hemorrhage ; but in practice this 
has not been found to occur, and the risk might generally be avoided 
by introducing the catheter at a distance from the placenta, the prob- 
able situation of which has been ascertained by auscultation. The 
more deeply the catheter is introduced, the more certain and rapid is 
its effect, and not less than seven inches should be pushed up within 
the os. It is not always easy to insert it so far, especially if a flexible 
catheter be used, which is apt to be too pliable to pass upward with 
ease. A solid bougie — male urethral bougie — should, therefore, be 
employed, or a hollow bougie containing a wire stilette, and I have 
found its introduction greatly facilitated by anaesthetizing the patient 
and passing the greater part of the hand into the vagina. In this 
way it can be pushed in very gently and without any risk of injury 
to the uterus. Previous to introducing the bougie it should be 
thoroughly asepticized by the 1 : 1000 solution, with which the vagina 
should also be well douched. There is some chance of rupturing the 
membranes while pushing it upward. This accident, indeed, cannot 
always be avoided, even when the greatest care is taken ; but when it 
occurs, the puncture will be at a distance from the os, so that a small 



INDUCTION OF PREMATURE LABOR. 477 

portion only of the liquor amnii will escape, and this can scarcely be 
considered a serious objection. It is always an advantage to allow the 
pains to conic on gradually, and in imitation of natural labor. There- 
fore, if, alter the bougie lias been inserted for a sufficient time, uterine 
contractions come on sufficiently strongly, we may leave the case to be 
terminated naturally; or, if they be comparatively feeble, we may 
resort to aecelerative procedures, viz., dilatation of the cervix by the 
fluid bags, and subsequently the puncture of the membranes. In 
this way we have the labor completely under control ; and I believe 
this method will commend itself to those who have experience of it, 
as the simplest and most certain mode of inducing labor yet known, 
and the one most closely imitating the natural process. Of late I 
have been in the habit of combining dilatation of the cervix with this 
method, by means of a well-carbolized sponge tent passed into the 
cervix after the bougie is in position. In ten or twelve hours, when 
the tent and bougie are removed, the cervix is found well dilated and 
ready for the passage of the child. 

[The most serious objection to the induction of premature labor is 
the frightful infantile mortality : that of the mothers is quite low in 
skilful hands. The late Dr. Cesare Belluzzi, of Bologna, recorded 112 
cases, with 8 deaths of women and 15 of the foetuses — 42 patients were 
treated in his private practice, and 70 in the Maternity of Bologna. 
In 9 patients labor was induced because of disease in the mother ; in 
1 it was brought on because the foetus had usually died in the ninth 
month of former pregnancies ; and in 102 the pelvis was contracted. 
Of these 102, 6 died — 3 out of 38 in private practice, and 3 out of 64 
in the hospital. Of the 9 women operated upon because of serious 
disease, 7 recovered. 35 out of 42 infants were delivered alive in 
private practice, and 62 out of 70 in the Maternity. The prolonged 
vitality of the foetus is largely dependent upon the period of gestation 
which is chosen for the operation ; the later the delivery, the better is 
the prospect of ultimate safety. But a small proportion of the chil- 
dren reach maturity. Of 32 delivered alive in hospital in a period of 
less than ten years under Dr. Belluzzi, 27 were dead before the expi- 
ration of the first year, and 29 in all within two years of birth. — Ed.] 

It should not be forgotten that the child is immature, and that 
unusual care is likely to be required to rear it successfully. Indeed, 
the large infantile mortality after the induction of premature labor 
forms the most serious objection to the operation. Thus Ludwig 
Winckel 1 published twenty-five cases of induced labor on account of 
contracted pelvis. The mothers all recovered, but fourteen of the 
children were stillborn; of the thirteen born alive, only seven survived 
a fortnight. If, therefore, we decide on the operation, the parents 
should be warned of the risks run by the child, although these are not 
of themselves a sufficient contra-indication to its adoption in suitable 
cases. We should, therefore, be careful to have at hand all the usual 
means of resuscitation ; and, as the mother may not be able to nurse 
at once, it would be a good precaution to have a healthy wet-nurse in 
readiness. 

1 See Harris's note to 6th American edition. 



478 



OBSTETRIC OPERATIONS. 



It is a matter of great importance to maintain the animal heat of 
premature children. For this purpose they are generally wrapped in 
cotton-wool and kept near the fire, but this is dirty and unsatisfactory, 
A far better and more hopeful procedure is to place the infant in an 
incubator or couveuse, 1 maintained at a uniform heat by means of a 
lamp, such as was first introduced by Tarnier. I used a modification 
of this apparatus, such as is here figured (Fig. 159), in a case in which 
the foetus could, at the most, have been at the sixth month, keeping it 
for three months in the heated chamber, at a temperature varying 

Fig. 159. 




Hearson's thermostatic nurse, c. Tank of warm water interposed between upper and lower 
compartments (a and b). d d. Slips of wood supporting cradle, s. Capsule containing a liquid 
which boils at the temperature at which it is desired to keep the chamber, a. From the centre of 
the capsule, s, a stiff wire passes out through the top of the apparatus, where it comes into contact 
with a light lever, v, Avhich is hinged at f. From the free end of this lever hangs a damper (w), 
which rests on the top of the chimney under which the flame burns. If the temperature in the 
compartment a rises too high, the fluid in the capsule (s) boils and expands the capsule, thus- 
raising the wire rod, which, acting on the lever v, at once lifts the damper (w) off the chimney, 
allowing the heat from the flame to escape by that outlet and preventing the further heating of 
the water, m. Aperture for entrance of air. o. Tray containing water. The centre of this tray is 
raised in the form of a cap (p), which fits over the aperture M, through which the air enters. It is 
perforated all around its sides, so that the air passes through it horizontally, as shown by the 
arrows, instead of rising vertically. Another tray (x) of very coarsely perforated zinc, somewhat 
smaller than the first, is turned upside down within it, and over this is fitted the coarse canvas (x), 
the edges of which are tucked into the water all around. Thus the air entering is constantly 
moistened as well as heated, r r. Flue shaped like the letter U, through which the heated air 
from the flame passes, so as to twice traverse the length of the. water-tank, and thus keep the water 
heated. In the top of the apparatus is a glass window through which the infant is kept in view. 
If a higher temperature than the boiling-point of the liquid within the capsule be desired, this 
can be obtained by moving the weight, t, along the lever toward the end to which the damper is 
attached. ' 

from 80° to 90° F., with a most satisfactory result. The apparatus is r 
however, costly, and requires a great deal of attention and supervision, 
so that it is clearly only suitable for use in maternity hospitals or in 
the houses of such patients as are able to incur the necessary expense. 

1 Auvard : " L»e la Couveuse pour Enfants," Arch, de Tocologie, Oct. 1883, p. 577. 



TUKNING. 479 



CHAPTEE II. 

TURNING. 

History of the Operation. — Turning, by which we mean the alter- 
ation of the position of the foetus, and the substitution of some other 
portion of the body for that originally presenting, is one of the most 
important of obstetric operations, and merits careful study. It is also 
one of the most ancient, and was evidently known to the Greek and 
Roman physicians. Up to the fifteenth century, cephalic version — 
that in which the head of the foetus is brought over the os uteri — was 
almost exclusively practised, when Pare and his pupil Guillemeau taught 
the propriety of bringing the feet down first. It was by the latter 
physician especially that the steps of the operation were clearly denned ; 
and the French have undoubtedly the merit both of perfecting its per- 
formance and of establishing the indications which should lead to its 
use. Indeed, it was then much more frequently performed than in 
later times, since no other means of effecting artificial delivery were 
known which did not involve the death of the child ; and practitioners, 
doubtless, acquired great skill in its performance, and were inclined to 
overrate its importance and extend its use to unsuitable cases. An 
opposite error was fallen into after the invention of the forceps, which 
for a time led to the abandonment of turning in certain conditions for 
which it was well adapted, and in which it has only of late years been 
again practised. 

Cephalic version has, since Pare wrote, been recommended and 
practised from time to time, but the difficulty of performing it satis- 
factorily was so great that it never became an established operation 
Dr. Braxton Hicks has perfected a method by which it can be accom- 
plished with greater ease and certainty, and which renders it a legiti- 
mate and satisfactory resort in suitable cases. To him we are also 
indebted for introducing a method of turning without passing the 
entire hand into the cavity of the uterus, which, under favorable 
circumstances, is not only easy of performance, but deprives the oper- 
ation of one of its greatest dangers. 

The possibility of effecting version by external manipulation has 
been long: known, and was distinctly referred to and recommended by 
Dr. John Pechey 1 so far back as the year 1698. Since that time it 
has been strongly advocated by Wigand and his followers ; and vari- 
ous authors in England, notably Sir James Simpson, have referred 
to the advantage to be derived from external manipulation assisting 
the hand in the interior of the uterus. In 1854 Dr. Wright, of 

1 The Complete Midwife's Practice, p. 142. 



480 OBSTETRIC OPERATION'S. 

Cincinnati, advocated the application of the bimanual method in arm 
and shoulder presentations, chiefly with the view of effecting cephalic 
version. To Dr. Hicks, however, incontestably belongs the merit of 
having been the first distinctly to show the possibility of effecting 
complete version in all cases in which the operation is indicated by 
combined external and internal manipulation, of laying down definite 
rules for its practice, and of thus popularizing one of the greatest im- 
provements in modern midwifery. 

The operation is entirely dependent for success on the fact that the 
child in utero is freely movable, and that its position may be artificially 
altered with facility. As long as the membranes are unruptured and 
the foetus is floating in the surrounding fluid medium, it is liable to 
constant changes in position, as may be readily demonstrated in the 
latter months of pregnancy ; and the operation, under these circum- 
stances, may be performed with the greatest facility. Shortly after the 
liquor amnii has escaped there is still, as a rule, no great difficulty in 
effecting version ; but, as the body is no longer floating in the sur- 
rounding liquid, its rotation must necessarily be attended with some 
increased risk of injury to the uterus. If the liquor amnii has been 
long: evacuated and the muscular structure of the uterus is strongly 
contracted, the foetus may be so firmly fixed that any attempt to move 
it is surrounded with the greatest difficulties, and may even fail en- 
tirely or be attended with such risks to the maternal structures as to 
be quite unjustifiable. 

Version may be required either on account of the mother or child 
alone ; or it may be indicated by some condition imperilling both, and 
rendering immediate delivery necessary. The chief cases in which 
it is resorted to, are those of transverse presentation, where it is 
absolutely essential ; accidental or unavoidable hemorrhage ; certain 
cases of contracted pelvis ; and some complications, especially prolapse 
of the funis. The special indications for the operation have been 
separately discussed under these subjects. 

Statistics and Dangers of the Operation. — The ordinary statis- 
tical tables cannot be depended on as giving any reliable results as to 
the risks of the operation. Taking all cases together, Dr. Churchill 
estimated the maternal mortality at one in sixteen, and the infantile as 
one in three. Like all similar statistics, they are open to the objection 
of not distinguishing between the results of the operation itself and 
of the cause which necessitated interference. Still, they are sufficient 
to show that the operation is not free from grave hazards, and that it 
must not be undertaken without due reflection. The principal dangers 
will be discussed as we proceed. It may suffice to mention here that 
those to the mother must vary with the period at which the operation 
is undertaken. If version be performed early, before the rupture of 
the membranes, or, in favorable cases, without the introduction of the 
hand into the interior of the uterus, the risk must of course be in- 
finitely less than in those more formidable cases in which the waters 
have long escaped, and the hand and arm have to be passed into an 
irritable and contracted uterus. But even in the most unfavorable 
cases accidents may be avoided if the operator bears constantly in mind 



TURNING. 481 

that the principal danger consists in laceration of the uterus or vagina 
from undue force being employed, or from the hand and arm not being 
introduced in the axis of the passages. There is no operation in which 
gentleness, absence of all hurry, and complete presence of mind are 
so essential. A certain number of cases end fatally from shock or 
exhaustion, or from subsequent complications. As regards the child 
the mortality is little, if at all, greater than in original breech and 
footling presentations. Nor is there any good reason why it should be 
so, seeing that cases of turning, after the feet are brought through the 
os, are virtually reduced to those of feet presentation, and that the 
mere versiou, if effected sufficiently soon, is not likely to add materially 
to the risk to which the child is exposed. 

The possibility of effecting version by external manipulation has been 
recognized by various authors, and was made the subject of an excellent 
thesis by Wigand, who clearly described the manner of performing the 
operation. In spite of the manifest advantages of the procedure, and 
the extreme facility with which it can be accomplished in suitable 
cases, it has by no means become the established custom to trust to it, 
and probably most practitioners have never attempted it, even under 
the most favorable conditions. The possibility of the operation is 
based on the extreme mobility of the foetus, before the membranes are 
ruptured. After the waters have escaped, the uterine walls embrace 
the foetus more or less closely, and version can no longer be readily 
performed in this manner. 

It may, therefore, be laid down as a rule that it should only be 
attempted when the abnormal position of the foetus is detected before 
labor has commenced, or in the early stage of labor, when the mem- 
branes are unruptured. It is also unsuitable for any but transverse 
presentations, for it is not meant to effect complete evolution of the 
foetus, but only to substitute the head for the upper extremity. It is 
useless whenever rapid delivery is indicated, for, after the head is 
brought over the brim, the conclusion of the case must be left to the 
natural powers. 

The manner of detecting the presentation by palpation has been 
already described (p. 129), and the success of the operation depends on 
our being able to ascertain the positions of the head and breech through 
the uterine walls. Should labor have commenced, and the os be dilated, 
the transverse presentation may be also made out by vaginal examina- 
tion. Should the abnormal presentation be detected before labor has 
actually begun, it is, in most cases, easy enough to alter it, and to bring 
the foetus into the longitudinal axis of the uterine cavity. Pinard 1 
recommends that after this has been done the foetus should be main- 
tained in position by a well-fitting elastic abdominal belt. It is seldom, 
however, discovered until labor has commenced, and even if it be 
altered the child is extremely apt to resume, in a short time, the faulty 
position in which it was formerly lying. Still there can be no harm 
in making the attempt, since the operation itself is in no way painful, 
and is absolutely without risk either to the mother or child. When 

1 De la Version par Manoeuvres externes. Paris, 1878. 
31 



432 OBSTETRIC OPERATIONS. 

the Transverse presentation is detected early in labor. I believe it is 
good practice to endeavor to remedy it by external manipulation, and. 
if it tails, we may at once proceed to other and more certain methods of 
operating. The procedure itself is abundantly simple. The patient 
is placed on her back, and the position of the foetus ascertained by 
palpation as accurately as possible, in the manner already described. 
The palms of the hands being then placed over the opposite poles of 
the foetus, by a series of gentle gliding movements the head is pushed 
toward the pelvic brim, while the breech is moved in the opposite 
direction. The facility with which the fetus may sometimes be moved 
in this way can hardly be appreciated by those who have never at- 
tempted the operation. As soon as the change is effected, the long 
diameters of the foetus and the uterus will correspond, and vaginal 
examination will show that the shoulder is no longer presenting and 
that the head is over the pelvic brim. If the os be sufficiently dilated, 
and labor in progress, the membranes should now be punctured, and 
the position of the foetus maintained for a short time by external 
pressure until we are certain that the cephalic presentation is perma- 
nently established. If labor be nut in progress, an attempt may at 
least be made to effect the same object by pads and a binder ; one pad 
being placed on the side of the uterus in the situation of the breech. 
and another on the opposite side in the situation of the head. 

On account of the difficulty of performing cephalic version in the 
manner usually recommended, it has practically scarcely been attempted. 
and. with the exception of some more recent authors, it is generally 
condemned by writers on systematic midwifery. Still, the operation 
offers unquestionable advantages in those transverse presentations in 
which rapid delivery is not necessary, and in which the only object of 
interference is the rectification of malposition ; for. if successful, the 
child is spared the risk of being drawn footling through the pelvis. 
The objections to cephalic version are based entirely on the difficulty 
of performance ; and. undoubtedly, to introduce the hand within the 
uterus, search tor. seize, and afterward place the slippery head in the 
brim of the pelvis, could not be an easy process, even under the most 
favorable circumstances, and must always be attended with consider- 
able risk to the mother. Velpeau, Avho strongly advocated the oper- 
ation, was of opinion that it might be more easily accomplished by 
pushing up the presenting part, than by seizing and bringing down 
the head. Wigand more distinctly pointed out that the head could be 
brought to a proper position by external manipulation, aided by the 
tinkers of one hand within the vagina. Braxton Hicks has laid down 
clear rules for its performance, which render cephalic versiun easy t:» 
accomplish under favorable conditions, and will doubtless cause it t o 
become a recognized mode of treating malpositions. The number of 
cases, however, in which it can be performed must always be limited, 
since, as in turning by external manipulation alone, it is necessary that 
the liquor amnii should be still retained, or at least have only recently 
escaped : that the presentation be freely movable about the pelvic brim : 
and that there be no necessity for rapid delivery. Dr. Hick- does not 
believe protrusion of the arm to be a contra-indication, and advis - 



TURNING. 483 



that it should be carefully replaced within the uterus. When, how- 
ever, protrusion of the arm has occurred, the thorax is so constantly 

pushed down into the pelvis that replacement can neither b - 
practicable, except under unusually favorable conditions, and podalic 
version will be oecessary. 

Method of Performance. — It is impossible to describe the method 
of performing cephalic version more concisely and clearly than in Dr. 
Hicks's own words. " Introduce," he says, " the left hand into the 
vagina, as in podalic version ; place the right hand on the outside of 
the abdomen, in order to make out the position of the fetus and the 
direction of its head and feet. Should the shoulder, for instance, pre- 
sent, then push it with one or two fingers in the direction of the feet. 
At the same time pressure with the other hand should be exerted on 
the cephalic end of the child. This will bring the head down to the 
os : then let the head be received on the tips of the two in-ide fingers. 
The head will play like a ball between the two hands : it will be under 
their command, and can be placed in almost any part at will. Let the 
head then be placed over the os, taking eare to rectify any tendency to 
face-presentation. It is as well, if the breech will not rise to the 
fundus readily, after the head is fairly in the os, to withdraw the hand 
from the vagina, and with it press up the breech from the exterior. 
The hand which is retaining gently the head from the outside should 
continue there for some little time, till the pains have insured the 
retention of the child in its new position and the adaptation of the 
uterine walls to its new form. Should the membranes be perfect, it is 
advisable to rupture them as soon as the head is at the os uteri ; during 
their flow and after, the head will move easily into its proper position." 

The procedure thus described is so simple, and would occupy so 
short a time, that there can be no objection to trying it. Should we 
fail in our endeavors, we shall not be in a worse position for effecting 
delivery by podalic version, which can be proceeded with without 
removing the hand from the vagina, or in any way altering the posi- 
tion of the patient. 

The method of performing podalic [or bi-polar] version varies with 
the nature of each particular case. In describing the operation it has 
been usual to divide the cases into those in which the circumstances 
are favorable and the necessary manoeuvres easily accomplished, and 
those in which there are likely to be considerable difficulties and 
increased risk to the mother. This division is eminently practicable, 
since nothing can be more variable than the circumstances under which 
version may be required. Before describing the steps of the operation, 
it may be well to consider some general conditions applicable to all 
cases alike. 

In England the ordinary position on the left side is usually em- 
ployed. On the Continent and in America the patient is placed "ii 
her back, with the legs supported by assistants, as in lithotomy. The 
former position is preferable, not only as a matter of custom, and as 
involving much less fuss and exposure of the person, but because it 
admits of both the operator'- hands being more easily used in concert. 
In certain difficult cases, when the liquor amnii has escaped and the 



484 OBSTETRIC OPERATIONS. 

back of the child is turned toward the spine of the mother, the dorsal 
decubitus presents some advantages in enabling the hand to pass more 
readily over the body of the child ; but such cases are comparatively 
rare. The patient should be brought to the side of the bed, across 
which she should be laid, with the hips projecting over and parallel 
to the edge, the knees being flexed toward the abdomen, and separated 
from each other by a pillow or by an assistant. Means should be 
taken to restrain the patient if necessary, and prevent her involun- 
tarily starting from the operator, as this might not only embarrass his 
movements, but be the cause of serious injury. 

The exhibition of anaesthetics is peculiarly advantageous. There is 
nothing which tends to facilitate the steps of the process so much as 
stillness on the part of the patient, and the absence of strong uterine 
contraction. When the vagina is very irritable and the uterus firmlv 
contracted around the body of the child, complete anaesthesia may 
enable us to effect version when without it we should certainly fail. 

It should be remembered that, since in all forms of version much 
manipulation is necessary, antiseptic precautions should be very rigidly 
enforced. 

The most favorable time for operating is when the os is fully dilated, 
before, or immediately after, the rupture of the membranes and the 
discharge of the liquor amnii. The advantage gained by operating 
before the waters have escaped cannot be overstated, since we can then 
make the child rotate with great facility in the fluid medium in which 
it floats. In the ordinary operation, in which the hand is passed into 
the uterus, it is essential to wait until the os is of sufficient size to 
admit of its being introduced with safety. This may generally be 
done when the os is the size of a crown-piece, especially if it be soft 
and yielding. 

The practice followed with regard to the hand to be used in turning 
varies considerably. Some accoucheurs always employ the right hand, 
others the left, and some one or other according to the position of the 
child. In favor of the right hand, it is said that most practitioners 
have more power with it, and are able to use it with greater gentleness 
and delicacy. In transverse presentations, if the abdomen of the child 
be placed anteriorly, the right hand is said to be the proper one to use, 
on account of the greater facility with which it can be passed over the 
front of the child ; and in difficult cases of this kind when we are 
operating with the patient on her back, it certainly can be employed 
with more precision than the left. In all ordinary cases, however, the 
left hand can be introduced much more easily in the axis of the pass- 
ages, the back of the hand adapts itself readily to the curve of the 
sacrum, and, even when the child's abdomen lies anteriorly, it can be 
passed forward without difficulty so as to seize the feet. These advan- 
tages are sufficient to recommend its use, and very little practice is 
required to enable the practitioner to manipulate with it as freely as 
with the right. If, in addition, we remember that the right hand is- 
required to operate on the foetus through the abdominal walls — and 
this is a point which should never be forgotten — we shall have abun- 
dant reasons for laying it down as a rule that the left hand should 



TURNING 



485 



generally be employed. Before passing the hand and arm they should 
be freely lubricated, with the exception of the palm, which is left 
untouched to admit a firm grasp being taken of the foetal limbs. It 
is also advisable to remove the coat, and bare the arm as high as the 
elbow. 

As it should be a cardinal rule to resort to the simplest procedure 
when practicable, it will be well to consider first the method by com- 
bined external and internal manipulation, without passing the hand 
into the uterus, and subsequently that which involves the introduction 
of the hand. 

Fig. 160. 




First stage of bi-polar version. 



Elevation of the head and depression of the breech. 
(After Barnes.) 



Turning- by Combined External and Internal Manipulation. — 
To effect podalic version by the combined method, it is an essential 
preliminary to ascertain the situation of the foetus as accurately as 
possible. It will generally be easy, in transverse presentations, to 
make out the breech and head by palpation ; while, in head presenta- 
tions, the fontanelles will show to Avhich side of the pelvis the face is 
turned. The left hand is then to be passed carefully into the vagina, 
in the axis of the canal, to a sufficient extent to admit of the fingers 
passing freely into the cervix. To effect this, it is not always neces- 
sary to insert the whole hand, three or four fingers being generally 
sufficient. 

If the head lie in the first (o.l.a.) or fourth (o.l.p.) position, push 
it upward and to the left ; while the other hand, placed externally on 



486 



OBSTETRIC OPERATIONS. 



the abdomen, depresses the breech toward the right (Fig. 160). By 
this means we act simultaneously on both extremities of the child's 
body, and easily alter its position. The breech is pushed down gently 



Fig. 161. 




Second stage of bi-polar version. Elevation of the shoulders and depression of the breech. 

(After Barnes.) 

but firmly, by gliding the hand over the abdominal wall. The head 
will now pass out of reach, and the shoulders will arrive at the os 
and will lie on the tips of the fingers. This is similarly pushed 

Fig. 162. 




Third stage of bi-polar version. Seizure of the knee and partial elevation of the head. 

(After Barnes.) 

upward in the same direction as the head (Fig. 161), the breech at the 
same time being still further depressed, until the knee comes within 
reach of the fingers, when (the membranes being uow ruptured, if still 



TURNING. 



487 



unbroken) it is seized and pulled down through the os (Fig. 162). 
Occasionally the foot comes immediately over the os, when it can be 
seized instead of the knee. Version may be facilitated by changing 
the position of the external hand, and pushing the head upward from 
the iliac fossa, instead of continuing the attempt to depress the breech 
(Figs. 162 and 163). These manipulations should always be carried 
on in the intervals, and desisted from when the pains come on ; and 
when the pains recur with great force and frequency, the advantage of 
chloroform will be particularly apparent. In the second (o.D.A.)^and 
third (o.d.p.) positions, the steps of the operation should be reversed ; 
the head is pushed upward and to the right, the breech downward and 
to the left. When the position cannot be made out with certaintv, it 



Fig. 163. 




Fourth stage of bi-polar version. Drawing down of the legs and completion of version. 

(After Barnes.) 



is well to assume that it is the first (o.l.a.), since that is the one most 
frequently met with ; and even if it be not, no great inconvenience is 
likely to occur. If the os be not sufficiently open to admit of de- 
livery being concluded, the lower extremity can be retained in its new 
position with one finger until dilatation is sufficiently advanced or 
until the uterus has permanently adapted itself to the altered position 
of the child, either of which results will generally be effected in a short 
space of time. 

In transverse presentations the same means are to be adopted, the 
shoulder being pushed upward in the direction of the head, while 
the breech is depressed from without. This is frequently sufficient 
to bring the knees within reach especially if the membranes are 



488 OBSTETRIC OPERATIONS. 

entire, but version is much facilitated by pressing the head upward 
from without, alternately with depression of the breech. If the liquor 
amnii has escaped and the uterus is firmly contracted round the body 
of the child, it will be found impossible to effect an alteration in its 
position without the introduction of the hand, and the ordinary 
method of turning must be employed. The peculiar advantage of the 
combined process is, that it in no way interferes with the latter, for, 
should it not succeed, the hand can be passed on into the uterus 
without withdrawal from the vagina (provided the os be sufficiently 
dilated), and the feet or knees seized and brought down. 

Turning with the hand introduced into the uterus, provided the 
waters have not or have only recently escaped and the os be sufficiently 
dilated, is an operation generally performed with ease. 

The first step, and one of the most important, is the introduction of 
the hand and arm. The fingers having been pressed together in the 
form of a cone, the thumb lying between the rest of the fingers, the 
hand, thus reduced to the smallest possible dimensions, is slowly and 
carefully passed into the vagina, in the axis of the outlet, in an inter- 
val between the pains, and passed onward in the same cautious manner 
and with a semi-rotatory motion until it lies entirely within the 
vagina, the direction of introduction being gradually changed from 
the axis of the outlet to that of the brim. If uterine contractions 
come on, the hand should remain passive until they are over. It 
should ever be borne in mind as one of the fundamental rules in per- 
forming version, that we should act only in the absence of pains, and 
then with the utmost gentleness — all force and violent pushing being 
avoided. The hand, still in the form of a cone, having arrived at the 
os, if this be sufficiently dilated, may be passed through at once. If 
the os be not quite open, but dilatable, the points of the fingers may 
be gently insinuated, and occasionally expanded, so as to press it open 
sufficiently to permit the rest of the hand to pass. While this is 
being done the uterus should be steadied by the other hand placed 
externally, or by an assistant. If the presentation should not previ- 
ously have been made out with accuracy, we can now ascertain how 
to pass the hand onward, so that its palmar surface may correspond 
with the abdomen of the child. 

Rupture of the Membranes. — The membranes should now be 
ruptured — if possible during the absence of pain, so as to prevent the 
waters being forced out. The hand and arm form a most efficient 
plug, and the liquor amnii cannot escape in any quantity. Some 
practitioners recommend that, before rupturing the membranes, the 
hand should be passed onward between them and the uterine walls, 
until we reach the feet. By so doing we run the risk of separating 
the placenta ; besides, we have to introduce the hand much farther 
than may be necessary, since the knees are often found lying quite 
close to the os. As soon as the membranes are perforated, the hand 
can be passed on in search of the feet (Fig. 164). At this stage of 
the operation increased care is necessary to avoid anything like force ; 
and should a pain come on, the hand must be kept perfectly fiat and 
still, and rather pressed on the body of the child than on the uterus. 



TURNING. 



489 



If the pains be strong, much inconvenience may be felt from the com- 
pression ; and were the onward movement continued, or the hand even 
kept bent in the conical form in which it was introduced, rupture of 
the uterine walls might easily be caused. This is not likely to occur 
in the class of cases now under consideration, for it is chiefly when 
the waters have long escaped that the progress of the hand is a matter 
of difficulty. Valuable assistance may now be given by pressing the 
breech downward from without, so as to bring the knees or feet more 
easily within the reach of the internal hand. Having arrived at the 
knees or feet, they may be seized between the fingers and drawn 

Fig. 164. 




Seizure of the feet when the hand is introduced into the uterus. 



downward in the absence of a pain (Fig. 165). This will cause the 
icetus to revolve on its axis, the breech will descend, and at the same 
time the ascent of the head may be assisted by the right hand from 
without. It is a question with many accoucheurs which part of the 
inferior extremities should be seized and brought down. Some recom- 
mend us to seize both feet, others prefer one only, while some advise 
the seizure of one or both knees. In a simple case of turning, before 
the escape of the waters, it does not matter much which of these plans 
is followed, since version is accomplished with the greatest ease by 
any one of them. The seizure of the knee, however, instead of the feet, 
offers certain advantages which should not be overlooked. It is gener- 
ally more accessible, affords a better hold (the fingers being inserted in 



490 



OBSTETRIC OPERATIONS 



the flexure of the ham), and, being nearer the spine, traction acts more 
directly on the body of the child. Any danger of mistaking the knee 
for the elbow may be obviated by remembering the simple rule that 
the salient angle of the former, when the thigh is flexed, looks toward 
the head of the child, of the latter toward its feet. Certain advantages 
may also be gained by bringing down one foot or knee only, instead of 
both. When one inferior extremity remains flexed on the body of the 
child, the part which has to pass through the os is larger than when 
both legs are drawn down, and consequently the os is more perfectly 
dilated, and less difficulty is likely to be experienced in the delivery 



Fig. 165. 




Drawing down of the feet and completion of version. 

of the rest of the body, so that the risk to the child is materially 
diminished. 

Simpson, whose views have been adopted by Barnes and other 
writers, recommends the seizing, if possible, in arm presentations, of 
the knee farthest from and opposite to the presenting arm, as by this 
means the body is turned round on its longitudinal axis, and the present- 
ing arm and shoulder more easily withdrawn from the os. Dr. Galabin 
has carefully investigated this point in a recent paper, 1 and contends 
that there is a greater mechanical advantage in seizing the leg which 



Obst. Trans, for 1877, vol. xix. p. 239. 



TUKNING. 



491 



is nearest to, and on the same side as, the presenting arm, and this, 
moreover, is generally more readily done. 

As soon as the head has reached the fundus, and the lower extremity 
is brought through the os, the case is converted into a foot or knee 
presentation, and it comes to be a question whether delivery should 
now be left to Nature or terminated by art. This must depend to a 
certain extent on the case itself, and on the cause which necessitated 
version, but, generally, it will be advisable to finish delivery without 
unnecessary delay. To accomplish this, downward traction is made 
during the pains, and desisted from in the intervals (Fig. 166). As 

Fig. 166. 




Showing the completion of version. (After Barnes.) 



the umbilical cord appears, a loop should be drawn down ; and if the 
hands be above the head, they must be disengaged and brought over 
the face, in the same manner as in an ordinary footling presentation. 
The management of the head, after it descends into the cavity of the 
pelvis, must also be conducted as in labors of that description. 

Turning' in Placenta Prsevia. — In cases of placenta praavia the 
os will, as a rule, be more easily dilatable than in transverse pres- 
entations. Hicks's method offers the great advantage of enabling us 
to perform version much sooner than was formerly possible, since it 
only requires the introduction of one or two fingers into the os uteri. 
Should we not succeed by it, and the state of the patient indicates that 
delivery is necessary, we have at our command, in the fluid dilators, a 



492 



OBSTETRIC OPERATIONS. 



means of artificially dilating the os uteri which can be employed with 
ease and safety. If we have to do with a case of entire placental 
presentation, the hand should be passed at that point where the 
placenta seems to be least attached. This will always be better than 
attempting to perforate its substance, a measure sometimes recom- 
mended, but more easily performed in theory than in practice. If the 
placenta only partially presents, the hand should, of course, be inserted 
at its free border. It will frequently be advisable not to hasten 
delivery after the feet have been brought through the os, for they form 
of themselves a very efficient plug, and eifectually prevent further 
loss of blood ; while, if the patient be much exhausted, she may have 
her strength recruited by stimulants, etc., before the completion of 
delivery. 

Fig. 167. 




Showing the use of the right hand in ahdomino-anterior position. 



Turning* in Abdomino -anterior Positions. — In abdomino-ante- 
rior positions, in which the waters have escaped, and in which, there- 
fore, some difficulty may be reasonably anticipated, the operation is 
generally more easily performed with the patient on her back ; the 
right hand is then introduced into the uterus, and the left employed 
externally (Fig. 167). In this way the internal hand has to be passed 
a shorter distance and in a less constrained position. The operator 
then sits in front of the patient, who is supported at the edge of the 
bed in the lithotomy position with the thighs separated, and the right 
haud is passed up behind the pubes and over the abdomen of the 
child. 

Difficult Cases of Arm Presentation. — The difficulties of turn- 
ing culminate in those unfavorable cases of arm presentation in which 
the membranes have been long ruptured, the shoulder and arm pressed 



TURNING. 493 

down into the pelvis, and the uterus contracted around the body of 
the child. The uterus being firmly and spasmodically contracted, the 

attempt to introduce the hand often only makes matters worse, by in- 
ducing more frequent and stronger pains. Even if the hand and arm 
he successfully passed, much difficulty is often experienced in causing 
the body of the child to rotate ; for we have no longer the fluid 
medium present in which it floated and moved with ease, and the arm 
of the operator may be so cramped and pained by the pressure of 
the uterine walls as to be rendered almost powerless. The risk of 
laceration is also greatly increased, and the care necessary to avoid so 
serious an accident adds much to the difficulty of the operation. 

Value of Anaesthesia in Relaxing" the Uterus. — In these per- 
plexing cases various expedients have been tried to cause relaxation of 
the spasmodically contracted uterine fibres, such as copious venesection 
in the erect attitude until fainting is induced, warm baths, tartar emetic, 
and similar depressing agents. None of these, however, is so useful 
as the free administration of chloroform, which has practically super- 
seded them all, and often answers most effectually when given to its 
full surgical extent. 

The hand must be introduced with the precautions already described. 
If the arm be completely protruded into the vagina, we should pass 
the hand along it as a guide, and its palmar surface will at once indi- 
cate the position of the child's abdomen. Xo advantage is gained by 
amputation, as is sometimes recommended. When the os is reached, 
the real difficulties of the operation commence, and, if the shoulder be 
firmly pressed down into the brim of the pelvis, it may not be easv to 
insinuate the hand past it. It is allowable to repress the presenting 
part a little, but with extreme caution, for fear of injuring the con- 
tracted uterine parietes. Herman 1 has pointed out that in some cases 
the difficulty is increased by the shoulder of the prolapsed arm being 
caught beneath the contraction ring (Bandl's), and he advises that it 
should be released by pressing it toward the centre of the cervical 
canal. It is better to insinuate the hand past the obstruction, which 
can generally be done by patient and cautious endeavors. Having- 
succeeded in passing the shoulder, the hand is to be pressed forward 
in the intervals, being kept perfectly flat and still on the body of the 
foetus when the pains come on. It is much safer to press on it than 
on the uterine walls, which might readily be lacerated by the projecting 
knuckles. AVhen the hand has advanced sufficiently far, it will be 
better, for the reasons already mentioned, to seize and bring down one 
knee only. 

When the Foot is Brought Down but the Foetus will not 
Revolve. — Even when the foot has been seized and brought through 
the os, it is by no means always easy to make the child revolve on its 
axis, as the shoulder is often so firmly fixed in the pelvic brim as not 
to rise toward the fundus. Some assistance may be derived from 
pushing the head upward from without, which, of course, would raise 
the shoulder along with it. If this should fail, Ave may effect our 

1 " Note on One of the Causes of Difficulty in Turning," Obst. Trans, for 1886, vol. xxviii. p. 150. 



494 OBSTETRIC OPERATIONS. 

object by passing a noose of tape or wire ribbon around the limb, by 
which traction is made downward and backward ; at the same time 
the other hand is passed into the vagina to displace the shoulder and 
push it out of the brim. It is evident that this cannot be done as long 
as the limb is held by the left hand, as there is no room for both hands 
to pass into the vagina at the same time. By this manoeuvre version 
may be often completed when the foetus cannot be turned in the 
ordinary way. Various instruments have been invented both for 
passing a fillet around the child's limb and for repressing the shoulder, 
but none of them can compete, either in facility of use or safety, with 
the hand of the accoucheur. 

Mutilation of the Foetus. — Should all attempts at version fail, no 
resource is left but the mutilation of the child, either by evisceration 
or decapitation. This extreme measure is, fortunately, seldom neces- 
sary, as with due care version may generally be effected, even under 
the most unfavorable circumstances. 1 



CHAPTER III. 

THE FOECEPS. 

Use of the Forceps in Modern Practice. — Of all obstetric opera- 
tions the most important, because the most truly conservative both to 
the mother and child, is the application of the forceps. In modern 
midwifery the use of the instrument is much extended, and it is now 
applied by some of our most experienced accoucheurs with a frequency 
which older practitioners would have strongly reprobated. That the 
injudicious and unskilful use of the forceps is capable of doing much 
harm, no one will for a moment deny. This, however, is not a reason 
for rejecting the recommendation of those who advise a more frequent 
resort to the operation, but rather for urging on the practitioner the 
necessity of carefully studying the manner of performing it, and of 
making himself familiar with the cases in which it is easy or the 
reverse. Nothing but practice — at first on the dummy, and afterward 
in actual cases — can impart the operative dexterity which it should be 
the aim of every obstetrician to acquire, and without which there can 
be no assurance of his doing his duty to his patient efficiently. 

Description. — The forceps may best be described as a pair of arti- 
ficial hands by which the foetal head may be grasped and drawn through 
the maternal passages by vis a fronte, when the vis a tergo is deficient. 
This description will impress on the mind the important action of the 
instrument as a tractor, to which all its other powers are subservient. 

i See note, p. 536. 



THE FORCEPS. 



495 



The forceps consists of two separate blades of a curved form, adapted 
to tit the child's head ; a lock by which the blades are united after 
introduction ; and handles which are grasped by the operator, and by 
means of which traction is made. It would be a wearisome and un- 
satisfactory task to dwell on all the modifications of the instrument 
which have been made, which are so numerous as to make it almost 
appear as if no one could practise midwifery with the least pretension 
to eminence, unless he has attached his name to a new variety of 
forceps. 

The Short Forceps. — The original instrument, invented by the 
Chamberlens, may be looked upon as the type of the short straight 
forceps, which has been more employed than any others and which, 
perhaps, finds its best representative in the short forceps of Denman 
(Fig. 168). Indeed, the only essential difference between the two is 

Fig. 168. 




Denman' s short forceps. 



the lock of the latter, originally invented by Smellie, which is so 
excellent that it has been adopted in all British forceps ; and which, 
for facility of juncture, is much superior to either the French pivot or 
the German lock, while for firmness it is, for all practical purposes, as 
good as either. In this instrument the blades are seven and the handle 
four and three-eighths inches in length ; the extremities of the blades 
are exactly one inch apart, and the space between them at their widest 
part is two and seven-eighths inches. The blades measure one and 
three-fourths inches at their greatest breadth and spring with a regular 



496 



OBSTETRIC OPERATIONS, 



sweep directly from the lock, there being no shank. The blades are 
formed of the best and most highly tempered steel, to resist the strain 
to which they are occasionally subjected, and they are smooth and 
rounded on their inner surface, to obviate the risk of injury to the 
scalp of the child. 

The special advantage claimed for this form of instrument is that, 
the two halves being precisely similar, no care or forethought is 
required on the part of the practitioner as to which blade should be 
introduced uppermost — an advantage of no great value, siuce no one 
should undertake a case of forceps delivery who has not sufficient 
knowledge of the operation, and presence of mind enough, to obviate 
any risk from the introduction of the wrong blade first. On account 
of its shortness, and the want of the second or pelvic curve, it is only 
adapted for cases in which the head is low down in the pelvis, or 
actually resting on the perineum. 

The Pelvic Curve. — The question of the second or pelvic curve is 
one on which there is much difference of opinion. The forceps we are 
now considering, and the many modifications formed on the same plan, 
is constructed solely with reference to its grasp on the child's head, 
and without regard to the axes of the maternal passages. Conse- 
quently, were we to introduce it when the head was at the upper part 
of the pelvis, we could not fail to expose the soft parts to the risk of 
contusion, and (in consequence of the necessity of drawing more directly 
backward) unduly stretch and even lacerate the perineum. Hence it 
is now admitted by obstetricians, with few exceptions, that the second 
curve is essential before the complete descent of the head, although it 
is not absolutely so after this has taken place. The only circumstances 
under which a straight blade can possess any superiority are in certain 
cases of occipito-posterior position, in which it is found necessary to 
rotate the head around a large extent of the pelvis, 
when the circular sweep of a strongly curved instru- 
ment might prove injurious. Such cases, however, 
are of rare occurrence, and need in no way influ- 
ence the general employment of the pelvic curve. 

Zeig-ler's Forceps. — The short forceps usually 
employed in Scotland is the invention of the late 
Dr. Zeigler (Fig. 169), and is useful from the facility 
with which the blades may be introduced in accurate 
apposition to each other, a point which in practice is 
of no little value. In general size and appearance it 
closely resembles Dennian's forceps, but the fenestra 
of the lower blade is continued down to the handle. 
In introducing, the lower blade is slipped over the 
handle of the other blade already in situ, and thus 
it is guided with great certainty into a proper 
position, locking itself as it passes on. This in- 
strument has the disadvantage of not having 
the second curve, but the facility of introduction 
has rendered it a great favorite with many who have been in the 
habit of employing it. 



Fig. 169. 




Zeigler' s forceps. 



THE FORCEPS. 



497 



The Long' Forceps. — For cases in which the head is not on the 
perineum, or at least not quite low in the pelvis, a longer instrument 
is essential. To meet this indication Smellie invented the long 
forceps, which, like the shorter instrument, has been very variously 
modified. The most perfect instrument of the kind employed in 
Great Britain is that known as Simpson's forceps (Fig. 170), which 
combines many excellent points selected from the forceps of various 
obstetricians, as well as some original additions, and which, as a whole, 
was never surpassed, until Tarnier's or its modification was invented. 

Fig. 170. 



Simpson's forceps. 



The curved portions of the blades are six and one-quarter inches 
long, the fenestra measuring one and one-quarter inches in its widest 
part. The extremities of the blades are one inch asunder when 
the handles are closed, and three inches at their widest part. The 
object of this somewhat unusual width is to lessen the compressing 
power of the instrument, without in any way interfering with its action 
as a tractor. The pelvic curve is less than in most long forceps, so as 
to admit of the rotation of the head when necessary, without the risk 
of injuring the maternal structures. Between* the curve of the blade 
and the lock is a straight portion or shank, measuring two and three- 
eighths inches, which, before joining the handle, is bent at right angles 
into a knee. This shank is a useful addition to all forceps, and is 

32 



498 OBSTETRIC OPERATIONS. 

essential in the long forceps to insure the junction of the blades beyond 
the parts of the mother, which might otherwise be caught in the lock 
and injured. The knees serve the purpose of preventing the blades 
from slipping from each other after they have been united. They also 
admit of one finger being introduced above the lock, and used as an 
aid in traction ; a provision which is made in some other varieties of 
long forceps by a semicircular bend in each shank. The handles, 
which in most British forceps are too small and smooth to afford a firm 
grasp, are serrated at the edge, and flattened from before backward, so 
as to fit the closed fist more accurately. At their extremities, near the 
lock, there are a pair of projecting rests, over which the fore and 
middle fingers may be passed in traction, and which greatly increase 
our power over the instrument. Although this and other varieties of 
the long forceps are specially constructed for application when the 
head is high in the pelvis, it answers quite as well as the short forceps 
— indeed, in most respects, better — when the head has descended low 
down. It is a decided advantage for the practitioner to habituate him- 
self to the use of one instrument, with the application and power of 
which he becomes thoroughly familiar. It is a mere waste of space 
and money for him to encumber himself with a number of instruments 
of various shapes and sizes, and he may be sure that a good pair of 
long forceps will be suitable for every emergency, and in any position 
of the head. 

The chief argument against the use of such an instrument in simple 
cases is its great power. This, however, is entirely based on a mis- 
conception. The existence of power does not involve its use, and the 
stronger instrument can be employed with quite as much delicacy and 
gentleness as the weaker. The remarks of Dr. Hodge 1 on this point 
are extremely apposite, and are well worthy of quotation. He says : 
" Certainly no man ought to apply the forceps who has not sufficient 
discretion to use no more force than is absolutely requisite for safe 
delivery. If, therefore, there is more power at command, he is not 
obliged to use it ; while, on the contrary, if much power be demanded, 
he can, within the bounds of prudence, exercise it by the long forceps, 
but with the short forceps his efforts might be unavailing. Moreover, 
in cases of difficulty, the short forceps being used, the practitioner 
would be forced to make great muscular efforts ; while with the long 
forceps, owing to the great leverage, such effort will be comparatively 
trifling, and, of course, the whole force demanded can be much more 
delicately, and at the same time efficiently, applied, and with more 
safety to the tissues of the child and its parent." 

Continental Forceps. — The forceps usually employed on the Con- 
tinent and in America differs considerably, both in appearance and 
construction, from those in use in England. As a rule it is a larger 
and more powerful instrument, joined by a pivot or button-joint, and 
it always possesses the second or pelvic curve. Of late years Simpson's 
forceps has been much employed in some parts of Germany. The 
chief objection to the Continental instruments is their cumbrousness.. 

1 System of Obstetrics, p. 242. 



THE FORCEPS 



499 



This is chiefly in the handles, which in many of them are forged in a 
piece with the blades, the part introduced within the maternal struc- 
tures not being materially different from the corresponding part of the 
English instrument. 

Tarnier's Forceps. — The forceps invented by Professor Tarnier 
(Fig. 171) has attracted considerable attention, and is highly esteemed 
by all who have used it. In this instrument traction is not made on 
the handles by which the blades are introduced as in ordinary forceps, 
but on a supplementary handle («) subsequently attached to the blades 
near the lower opening of their fenestra? (6). The advantage claimed 
for this arrangement is that less force is required in traction, which can 



Fig. 171. 



Fig. 172. 





Tarnier's forceps. [■] 



Simpson's axis-traction iorceps. 
e,b. Traction handle. c,f. Line of traction. 



always be made in the proper axis of the pelvis ; that the blades are 
not likely to slip ; and that rotation of the head is not interfered 
with. The handles of the forceps, moreover, guide the operator to the 
direction in which he ought to pull, since all that is required is to 
keep the traction rods parallel to them. This instrument, however, 
although theoretically excellent, is somewhat too complicated for 
general use. 

Simpson's Axis-traction Forceps. — Prof. A. E. Simpson, of 
Edinburgh, has invented a modification of Tarnier's instrument, which 
he calls the " Axis-traction Forceps " (Fig. 172). The supplementary 
handles are fixed to the blades, and the whole mechanism is much 
simpler than in Tarnier's forceps. Dr. Simpson reports very favorably 
of this forceps, and it is certainly well adapted for the object aimed at. 



[ l The original Tarnier forceps had blades somewhat like those of Davis, and was much better 
than his present style, in the estimation of many accoucheurs. — En.] 



500 OBSTETRIC OPERATIONS. 

For some years I have used it to the exclusion of every other form, 
and have every reason to be satisfied with it, especially in the high 
forceps operation, in which it seems to me superior to any other instru- 
ment. Indeed, the facility with which it effects delivery in such cases 
is often very striking. 

Action of the Instrument. — The forceps is generally said to act in 
three different ways : 

First. As a tractor. 
Second. As a lever. 
Third. As a compressor. 

It is more especially as a tractor that the instrument is of value, and 
it is used with the greatest advantage when it is employed merely to 
supplement the action of the uterus which is insufficient of itself to 
effect delivery, or when, from some complication, it is necessary to 
complete labor with greater rapidity than can be accomplished by the 
unaided powers of Nature. In most cases traction alone is sufficient ; 
but in order that it may act satisfactorily, and that the instrument may 
not slip, a proper construction of the forceps, and a sufficient curvature 
of the blades, are essential. The want of these is the radical fault of 
many of the short, straight instruments in common use, which have a 
tendency to slip during our efforts at extraction. 

The forceps acts also as a lever, but this action has been greatly ex- 
aggerated. It is generally described as a lever of the first class, the 
power being at the handles, the fulcrum at the lock, and the weight at 
the extremities. There may possibly be some leverage power of this 
kind when the instrument is first introduced, and the handles held so 
loosely that one blade is able to work on the other. But, as ordinarily 
used, the handles are held with a sufficiently firm grasp to prevent this 
movement, and then the two blades practically form a single instru- 
ment. 

Galabin, who has studied this subject in detail, points out 1 that : 
" 1. The lever is formed by both blades of the forceps and the foetal 
head united in one immovable mass. As soon as the blades begin to 
slip over the head, the lever is decomposed, and the swaying movement 
ceases to have any mechanical advantage. 2. The power is applied to 
the handles in a slanting direction. The resistance or weight does not 
act at a point either between the former and the fulcrum, or beyond 
the fulcrum, but at a point in a plane nearly at right angles to the line 
joining these two points, and its direction is a line perpendicular to 
that plane of the pelvis in which the greatest section of the head is 
engaged ; that is to say, in the case of straight forceps, nearly parallel 
to the handles. The lever formed does not, therefore, strictly speak- 
ing, belong to anv one of the three orders into which levers are com- 
monly divided. 3. The fulcrum is fixed partly by friction, partly by 
the combination of traction with oscillatory movements — in other 
words, by the power being directed in great measure downward, and 
only slightly to one side." 

He further shows that the pendulum motion of the forceps is super- 

1 Galabin : "Action of Midwifery Forceps as a Lever," Obst. Journ., 1876-77, vol. iv. p. 508. 



THE FORCEPS. 501 

fluous in all ordinary forceps operations, in which traction alone is 

amply sufficient for delivery ; but that when the head i- impacted, and 
great force i- required for its extraction, a mechanical advantage may 
he gained from having recourse to an oscillatory movement, which 
should, however, be very limited, and only continued if found to effect 
distinct advance of the head. 

Regarding the compressive power of the instrument there has been 
much difference of opinion. There is do doubt that the forceps, espe- 
cially some of the foreign instruments in which the points nearly 
approach each other, is capable of exerting considerable compression 
on the head. It is. however, extremely problematical if this action be 
of real value. It is to be borne in mind that in eases of protracted 
labor the head has been already moulded and compressed, and the 
bones have been made to overlap each other to their utmost extent, by 
the sides of the pelvis. We can scarcely, therefore, expect to diminish 
the head much more by the forceps without employing an amount of 
force that will seriously endanger the life of the child. It is in cases 
of disproportion between the head and the pelvis, depending on slight 
antero-posterior contraction of the pelvic brim, that diminution of the 
child's head by compression would be most useful. Then, however, 
the pressure of the forceps is exerted on that portion of the head which 
lies in the most roomy diameter of the pelvis, where there is no want 
of space. If this pressure does not increase the opposite diameter, which 
is in apposition to the narrower portion of the pelvis, it can at least 
do nothing toward lessening it. and diminution of any other part of 
the child's head is not required. 

Dynamical Action of the Forceps. — The mere introduction of 
the forceps sometimes excites increased uterine action, through the 
reflex irritation induced by the presence of a foreign body in the 
vagina. This has been called the dynamical action of the forceps ; 
but it cannot be looked upon in any other light than that of an occa- 
sional accidental result. 

The circumstance- indicating the use of the forceps have been sepa- 
rately considered elsewhere, and to recapitulate them here would only 
lead to needless repetition. I shall, therefore, now merely describe the 
mode of using the instrument. 

Before doing s<:> it is well to repeat what has already been said as to 
the difference between what may be termed the high and low forceps 
operations. The application of the instrument when the head is low 
in the pelvis is extremely simple : and when there is no disproportion 
between the head and the pelvis, and some slight traction is alone 
required to supplement deficient expulsive power, the operation, in the 
hands of any ordinarily well instructed practitioner, ought to be per- 
fectly safe both to the mother and child. It is very different when the 
head is arrested at the brim, or high in the pelvis. Then the applica- 
tion of the forceps is an operation requiring much dexterity for its 
proper performance, and must never be undertaken without anxious 
consideration. It is because these two classes of operations have been 
confused that the use of the instrument is regarded by many with such 
unreasonable dread. 



502 OBSTETRIC OPERATIONS. 

Preliminary Considerations. — Before attempting to introduce the 
forceps, there are several points to which attention should be directed. 

1st. The membranes must, of course, be ruptured. 

2d. For the safe and easy application of the instrument, it is also 
advisable that the os should be fully dilated, and the cervix retracted 
over the head. Still these two points cannot be regarded, as many 
have laid down, as being sine qua non. Indeed, we are often com- 
pelled to use the instrument when, although the os is fully dilated, the 
rim of the cervix can be felt at some point of the contour of the head, 
especially in cases in which the anterior lip is jammed between the 
head and the pubes. Provided due care be taken to guard the cervical 
rim with the fingers of one hand, as the instrument is slipped past it, 
there need be no fear of injury from this cause. If the os be not fully 
dilated, but is sufficiently open to admit of the passage of the forceps, 
the operation, under urgent circumstances, may be quite justifiable, but 
it must necessarily be a somewhat anxious one. 

3d. The position of the head should be accurately ascertained by 
means of the sutures and fontanelles. Unless this be done, the opera- 
tion will always be hap-hazard and unsatisfactory, as the practitioner 
can never be in possession of accurate knowledge of the progress of 
the case. It may be that the occiput is directed backward ; and, 
although that does not contra-indicate the application of the forceps, 
it involves special precautions being taken. 

4th. The bladder and bowels should be emptied. 

Question of Administering' Anaesthetics. — Before proceeding to 
operate, the question of anaesthesia will arise. In any case likely to 
be difficult it is of the greatest assistance to have the patient completely 
under the influence of an anaesthetic to the surgical degree, so as to 
have her as still as possible ; but, whenever this is deemed necessary, 
another practitioner should undertake the responsibility of the admin- 
istration. In simple cases I believe it is better to dispense with 
anaesthetics altogether, partly because they are apt to stop what pains 
there are, which is in itself a disadvantage, but chiefly because, under 
partial anaesthesia, the patient loses her self-control, is restless, and 
twists herself into awkward positions, which gives rise to the utmost 
difficulty and inconvenience in the use of the instrument. Moreover, 
if no anaesthetic be given, the patient can assist the operator by placing 
herself in the most convenient attitude. 

Description of the Operation. — In describing the method of apply- 
ing the forceps, I shall assume that we have to do with the simpler 
variety of the operation, when the head is low in the pelvis. Subse- 
quently I shall point out the peculiarities of the high operation. 

As to the position of the patient, I believe there can be no doubt of 
the superiority of that which is usually adopted in Great Britain. On 
the Continent and in America the forceps is always employed with the 
patient lying on her back, a position involving much needless exposure 
of the person, and requiring more assistance from others. In certain 
cases of unusual difficulty the position on the back is of unquestionable 
utility, but we may, at least, commence the operation in the usual way 
and subsequently turn the patient on her back if desirable. 



THE FORCEPS. 503 

Much of the facility with which the blades are introduced depeuds 
on the patient being properly placed. Hence, although it gives rise to 
a little more trouble at first, I believe that it is always best to pay 
particular attention to this point, whether the high or low forceps 
operation be about to be performed. The patient should be brought 
quite to the side of the bed, with her nates parallel to and projecting 
somewhat over its edge. The body should lie almost directly across 
the bed, and nearly at right angles to the hips, with the knees raised 
toward the abdomen (Fig. 173). In this way there is no risk of the 
handle of the upper blade, when depressed in introduction, coming in 
contact with the bed. 

Fig. 173. 



Position of patient for forceps delivery and mode of introducing lower blade. 

Antiseptic Precautions. — Previous to use the blades should be 
carefully disinfected. This is best done by thoroughly heating them 
in the flame of a spirit lamp, and then placing them in hot water and 
creolin. They should then be lubricated with carbolized vaseline and 
placed ready to hand. 

These preliminaries having been attended to, we proceed to the 
introduction of the blades, sitting by the side of the bed, opposite the 
nates of the patient. 

The important question now arises, In what direction are the blades 
to be passed ? The almost universal rule in our standard works is, 
that they must be passed as nearly as possible over the child's ears, 
without any reference to the pelvic diameters. Hence, if the head 
have not made its turn, but is lying in one oblique diameter, the blades 
would require to be passed in the opposite oblique diameter ; in short, 
the position of the forceps, as regards the pelvis, must vary according 
to the position of the head. Some have even laid down the rule that 
the forceps is contra-indicated unless an ear can be felt — a rule that 
would very seriously limit its application, as in many cases in which 



504: OBSTETEIC OPERATIONS. 

it is urgently required it is a matter of great difficulty, and even im- 
possibility, to feel the ear at all. It is admitted that in the high 
forceps operation the blades must be introduced in the transverse 
diameter of the pelvis, without relation to the position of the head. 
On the Continent it is generally recommended that this rule should be 
applied to all cases of forceps delivery alike, whether the head be high 
or low, and I have now for many years adopted this plan, and passed 
the blades in all cases, whatever be the position of the head, in the 
transverse diameter of the pelvis, without any attempt to pass them 
over the bi-parietal diameter of the child's head. Dr. Barnes points 
out with great force that, do Avhat we will, and attempt as we may to 
pass the blades in relation to the child's head, they find their way to 
the sides of the pelvis, and that the marks of the fenestra? on the head 
always show that it has been grasped by the brow and side of the 
occiput. [ l ] Of the perfect correctness of this observation I have no 
doubt ; hence, it is a needless element of complexity to endeavor to 
vary the position of the blades in each case, and one which only con- 
fuses the inexperienced practitioner, and renders more difficult an 
operation which should be simplified as much as possible. While, 
therefore, it is of importance that the precise position of the head 
should be ascertained in order that we may have an intelligent notion 
of its progress, I do not think that it is essential as a guide to the 
introduction of the forceps. 

Method of Introducing- the Lower Blade. — As a rule, the lower 
blade, lightly grasped between the tips of the index and middle fingers 
and the thumb, should be introduced first. Poised in this way, we 
have perfect command over it, and can appreciate in a moment any 
obstacle to its passage. Two or more fingers of the left hand are 
introduced into the vagina, and by the side of the head, as a guide. 
The greatest care must be taken, if the cervix be within reach, that 
they are passed within it, so as to avoid the possibility of injury. 

The handle of the instrument has to be elevated, and its point slid 
gently along the palmar surface of the guiding fingers until it touches 
the head (Fig. 173). At first the blade should be inserted in the axis 
of the outlet, but as it progresses the handle must be depressed and 
carried backward. As it is pushed onward it is made to progress by 
a slight side-to-side motion, and it is of the utmost importance to bear 
in mind that the greatest gentleness must always be used. If any 
obstruction be felt, we are bound to withdraw the instrument, partially 
or entirely, and attempt to manoeuvre, not force, the point past it. As 
the blade is guided on in this way, it is made to pass over the con- 
vexity of the head, the point being always kept slightly in contact 
with it, until it finally gains its proper position. When fully inserted 
the handle is drawn back toward the perineum, and given in charge 
to an assistant. The insertion must be carried on only in the inter- 
vals between the pains, and desisted from during their occurrence ; 
otherwise there would be a serious risk of injuring the soft parts of 
the mother. 

t 1 If the forceps has a form to fit the sides of the head, it will not rotate within the blades.— Ed.1 



THE FORCEPS. 505 

Introduction of the Upper Blade. — The second blade is passed 
directly opposite to the first, and is generally somewhat more difficult 

to introduce, in consequence of the space occupied by the latter. It 
is passed along two fingers directly opposite the first blade, and with 

exactly the same precautions as to direction and introduction, except 
that at first its handle has to be depressed instead of elevated (Fig. 
174). 

The handle which was in charge of the assistant is now laid hold of 
by the operator, and the two handles are drawn together. If the 
blades have been properly introduced, there should be no difficulty in 
locking ; but, should we be unable to join them easily, we must with- 
draw one or other, either partially or entirely, and reintroduce it with 
the same precautions as before. "We must also assure ourselves that 
no hairs, or any of the maternal structures, are caught in the lock. 



Introduction of the upper blade. 

Method of Traction. — When once the blades are locked we may 
commence our efforts at traction. To do this we lay hold of the 
handles with the right hand, using only sufficient compression to give 
a firm grasp of the head and to keep the blades from slipping. The 
left hand may be advantageously used in assisting and supporting the 
right during our efforts at extraction, and, at a late stage of the opera- 
tion, may be employed in relaxing the perineum when stretched by 
the head of the child. Traction must always be made in reference to 
the pelvic axes, being at first backward toward the perineum (Fig. 
175), in the direction of the axis of the brim, and as the head descends 
and the vertex protrudes through the vulva, it must be changed to 
that of the outlet (Fig. 176). If the axis-traction forceps is used, it 
is to be borne in mind that traction is to be made by the traction 
handle only, the handles of the instrument itself being left untouched 



506 



OBSTETRIC OPERATIONS. 



after they are locked and the traction rods are united. By keeping 
these latter parallel to the handles of the forceps, traction can always 
be made in the proper direction. We must extract only during the 
pains ; and, if these should be absent, we must imitate them by acting 
at intervals. This is a point which deserves special attention, for 
there is no more common error than undue hurry in delivery. 

The only valid objection I know of against a more frequent resort 
to the forceps in lingering labor is, that the sudden emptying of the 
uterus, in the absence of pains, may predispose to hemorrhage ; and it 
cannot be denied that it is one of some weight. However, if due care 
be taken to operate slowly, and to allow several minutes to elapse be- 
tween each tractive effort, while at the same time uterine contractions 
are stimulated by pressure and support, this need not be considered 



Fig. 175. 




Forceps in position. Traction in the axis of the brim, downward and backward. 

a contra-indication. Besides direct traction we may impart to the 
instrument a gentle waving motion from handle to handle, which 
brings into operation its power as a lever ; but this must be done only 
to a very slight extent, and must always be subservient to direct trac- 
tion. 

Proceeding thus in a slow and cautious manner, carefully regulating 
the force employed according to the exigencies of the case, we shall 
perceive that the head begins to descend ; and its progress should be 
determined, from time to time, by the fingers of the unemployed hand. 

When the head lies in the oblique diameter, as it descends, in con- 
sequence of its perfect adaptation to the pelvic cavity it will turn into 
the antero-posterior diameter without any effort on the part of the 
operator, provided only that the traction be sufficiently slow and 
gradual. As the head is about to emerge, it is necessary to raise the 



THE FORCE 1'S. 



507 



handles toward the mother's abdomen. More than usual care is re- 
quired to prevent laceration of the perineum, which isalwaysmuch 
stretched (Fig. 176). If, as often happens, the pains have now in- 
creased,and the perineum be very thin and tense, it may even be desir- 
able to remove the blades gently and leave the case to be terminated 
by the natural powers ; but if due precautions are used this need not 
be necessary. 

The peculiarities of forceps delivery in occipito-posterior positions 
have already been discussed (p. 3So), and need not be repeated. 

High Forceps Operations. — When high forceps operation has been 
decided on, the passage of the blades will be found to be much more 
difficult, from the height of the presenting part, the distance which 



Fig. 176. 




Last stage of extraction. The handles of the forceps are being gradually turned upward 
toward the mother's abdomen. 

they must pass, and, in some cases, from the mobility of the head 
interfering with their accurate adaptation. The general principles of 
introduction and of traction are, however, identical. This operation 
will very rarely be attempted before the head has entered or become 
fixed in the pelvic brim, for if it be freely movable above the brim, 
turning is preferable. If, however, from long draining away of the 
waters, or rigidity of the uterus, we are induced to attempt the opera- 
tion before the head has entered the brim, it must be fixed as much as 
possible by abdominal pressure. In guiding the blades to the head 
special care must be taken to avoid any injury of the soft parts, espe- 
cially if the cervix be not completely out of reach. For this purpose 
it may even be advisable to introduce the entire left hand as a snide. 



508 OBSTETRIC OPERATIONS. 

so as to avoid any possibility of injuring the cervix from not passing 
the instrument under its edge. 

Peculiar Method of Introducing- the Blades. — Some authors 
advise that, in such cases, the blade should be introduced at first oppo- 
site the sacrum, until the point approaches its promontory. It is then 
made to sweep round the pelvis, under the protecting fingers, till it 
reaches its proper position on the head. This plan is advocated by 
Ramsbotham, Hall Davis, and other eminent practical accoucheurs,, 
and it is certainly of service in some cases of difficulty ; especially 
when, from any reason, it is not possible to draw the nates over the 
edge of the bed, when the necessary depression of the handle of the 
upper blade is difficult to effect. It involves, however, a somewhat 
complicated manoeuvre, and it is seldom that the blades cannot be 
readily introduced in the usual way. 

In locking, the slightest approach to roughness must be carefully 
avoided, for the extremities of the blades are now within the cavity of 
the uterus, and serious injury might easily be inflicted. If difficulty 
be met with, rather than employ any force, one of the blades should 
be withdrawn and reintroduced in a more favorable direction. If 
the blades have shanks of sufficient length, there should be no risk of 
including the soft parts of the mother in the lock, which, in a badly 
constructed instrument, is an accident not unlikely to occur. 

Method of Traction. — After junction, traction must at first be 
altogether in the axis of the brim, and to effect this the handles must 
be pressed well backward toward the perineum. As the head descends 
it will probably take the usual turn of itself, without effort on the 
part of the operator, and the direction of the tractive force may be 
gradually altered to that of the axis of the outlet. If the pains be 
strong and regular, and there be no indication for immediate delivery, 
we may remove the forceps after the head has descended upon the 
perineum, and leave the conclusion of the case to Mature. This course 
may be especially advisable if the perineum and soft parts be unusually 
rigid ; but generally it is better to terminate labor without removing 
the instrument. 

Possible Dangers of Forceps Delivery. — Before concluding this 
subject, reference may be made to the possible dangers of the opera- 
tion. I would here again insist on the importance of distinguishing 
between the high and low forceps operations, which have been so 
unfortunately and unfairly confounded. Reasons have already been 
given for rejecting the statistics of the risks attending forceps delivery 
in the latter class of cases (p. 363). A formidable catalogue of 
dangers, both to mother and child, might easily be gathered from our 
standard works on obstetrics. Among the former the principal are 
lacerations of the uterus, vagina, and perineum ; rupture of varicose 
veins, giving rise to thrombus ; pelvic abscess from contusion of the 
soft parts ; subsequent inflammation of the uterus or peritoneum ; 
tearing asunder of the joints and symphyses ; and even fracture of the 
pelvic bones. A careful analysis of these, such as has been so well 
made by Drs. Hicks and Phillips, 1 proves beyond doubt that the 

i Obst. Trans., 1872, vol. xiii., p. 55. 



THE FORCEPS. 509 

application of the instrument is not so much concerned in their 
production as the protraction of the labor, and the neglect of the prac- 
titioner in not interfering sufficiently soon to prevent the occurrence 
of the evil consequences, afterward attributed to the operation itself. 
Many of these will be found to arise from the prolonged pressure on 
the soft parts within the pelvis and the subsequent inflammation or 
sloughing. To these causes may be referred with propriety most cases 
of vesico-vaginal fistula (p. 459), peritonitis, and metritis following 
instrumental labor. 

Lacerations and similar accidents may, however, result from an 
incautious use of the instrument. Slight lacerations of the mucous 
membrane of the vagina are probably far from uncommon. But if 
these cases were closely examined it would be found that the fault lay 
not in the instrument, but in the hand that used it. Either the blades 
were introduced without due regard to the axes of the pelvis, or they 
were pushed forward with force and violence, or an instrument was 
employed unsuitable to the case (such as a short straight forceps when 
the head was high in the pelvis), or undue haste and force in delivery 
were used. It would be manifestly unfair to lay the blame of such 
results upon the forceps, which, in the hands of a more judicious and 
experienced practitioner, would have effected the desired object with 
perfect safety. The instrument is doubtless unsafe in the hands of 
anyone who does not understand its use, just as the scalpel or ampu- 
tating knife would be in the hands of a rash and inexperienced 
surgeon. The lesson to be learnt seems to be, clearly, not that the 
dangers should deter us from the use of the forceps, but that they 
should induce us to study more carefully the cases in which it is 
applicable and the method of using it with safety. 

Possible Risks to the Child. — The dangers to the child are, prin- 
cipally, lacerations of the integuments of the scalp and forehead ; 
contusion of the face ; partial, but temporary, paralysis of the face 
from pressure of a blade on the facial nerve ; depression or fracture of 
the cranial bones ; injury to the brain from undue pressure of the 
blades. These evils are of rare occurrence, and, when they do happen, 
generally result from improper management of the operation — such as 
undue compression, the use of improper instruments, or excessive and 
ill-directed efforts at traction — and cannot, therefore, be considered as 
in any way contra-indicating the use of the instrument. Many of 
the more common results, such as slight abrasions of the scalp or 
paralysis of the face, are transitory in their nature and of no real 
consequence. 

[The Forceps in America. — Although the obstetrical forceps was 
first used in England, other countries in the march of improvement 
have made great changes, not only in the original forms, but in the 
manner of use, and various shapes, as well as different positions of the 
woman in application, have become in a measure national. With the 
exception of having adopted almost exclusively the French and German 
dorsal decubitus in making use of the instrument, we have become in a 
measure eclectic in the selection of the latter : medical schools, accouch- 
eurs, and local obstetrical societies influencing students and the junior 



510 OBSTETRIC OPERATIONS. 

members of the profession to adopt the French, German, English, or 
American style, as the case may be, the forceps themselves bearing the 
names of the several inventors or compilers ; for some are a true com- 
pilation — the blade from one contriver ; fenestral openings, another ; 
pelvic curve, a third; width, a fourth; shanks, a fifth; method of 
locking, a sixth, etc. For this reason the late Prof. Hodge named his 
forceps the eclectic, although in some respects entirelv original, particu- 
larly in the long superimposed shanks — a great improvement for oper- 
ating at the superior strait and avoiding the painful stretching of the 
posterior commissure of the vulva. Dr. Hodge expended a great deal 
of thought and money in perfecting his forceps, and the various steps 
in the process were marked by a new form, until, from a heavy, clumsy 
instrument, he gradually evolved what was at one time regarded as a 
wonderful improvement upon the forceps of France and England. 

A contemporary of Prof. Hodge, the late Prof. David D. Davis, of 
London, was equally anxious to perfect the instrument, and turned 
his attention especially to making the blades light, open, and to fit the 
sides of the foetal head so as to enable traction to be made without 
much pressure or leaving any mark on the child's scalp. There is a 
principle of mechanics involved in his instrument which he studied to 
perfect by moulding the blades upon an iron foetal head so as to obtain 
considerable coaptating surface, and thus by increase of friction to 
avoid undue and dangerous pressure. The Davis blade soon began to 
effect changes in the form of American forceps, and by the addition of 
long handles and some alterations of shape, weight, and curve became 
a leading feature in those bearing the names of Prof. Wallace, of the 
Jefferson Medical College, Dr. Bethel, and Albert H. Smith, all of 
this city. The short Davis instrument was a great favorite with the 
late Prof. Meigs and Dr. William Harris, both largely engaged in 
obstetrical practice as well as teaching ; and many a delicate woman 
with wasting forces was aided in her delivery at their hands, and was 
surprised to find no mark on the baby's head, and that her own 
sufferings could be so gently and safely relieved. 

Although such was the estimation of the Davis blade, and still is in 
many parts of our country, it does not appear to have retained its 
popularity or been adopted, as its mechanical perfection would lead 
one who appreciates it to suppose it would have been. In Great 
Britain the favorite forms now in use are but a very slight improve- 
ment upon the forceps of a hundred years ago except in finish and 
material, the open fenestra and bevelled blades of Davis being declined 
in favor of the looped fenestra and flat-edged blades in use when he 
made his experiments and changes. This appears to have grown out 
of a practice which has been largely adopted in Germany, Great 
Britain, and many parts of the United States in applying the forceps 
to the foetal head, the blades being introduced at the sides of the 
pelvis without much reference to the position which the head occupies. 
As compression is objected to, the blades are made long and widely 
separated (three and a quarter to three and a half inches), and the 
handles short, so as not to allow of much leverage. As the blades do 
not fit the head, the mechanism of labor as taught by Hodge has been 



THE FORCEPS. 511 

much simplified, as it is nor accessary to learn all the oblique fittings 
of the fenestra over the 'parietal protuberances or ears. Dr. Meigs 
used to tell the students that the forceps was the child's instrument, 
and should be used as a tractor; and for this reason he advocated the 
use of the Davis blades against those of Siebold, Levret, Baudelocque, 
and Haighton, employed generally in our country fifty years ago. 
His language is not very complimentary to what he denominates by 
distinction the mother's instrument, the form being better adapted for 
saving the woman than the fetus. [ J ] 

At the present day we have two general orders of forceps in use in 
the United States, under each of which may be placed a vast number 
of special varieties which are simply changes upon one or the other 
general type according to the fancy of the inventor. At the head of 
one type may be placed the long forceps of Prof. Hodge, designed to 
be adapted to the sides of the child's head in all possible cases ; and of 
the other, those of Prof. James Y. Simpson, of Edinburgh, or their 
modification by Profs. Elliot and Bedford, of Xew York, intended to 
be used as tractors, and applied in reference to the sides of the mother's 
pelvis, rather than to those of the infant's head.[ 2 ] 

Taking the long forceps of Levret and Baudeloccpie as improved 
and modified by Hodge, with the blades of Prof. Davis as a substitute, 
and handles of less curve than those of Hodge, and we have the long 
forceps of the late Prof. Ellerslie Wallace, of Jefferson Medical College, 
at one time a very favorite variety and largely used. Xext in order 
are the instruments of Hodge, Davis, and Simpson, Elliot, Bedford, 
and a few r others — in all about a dozen forms that vary in popularity. 
The improvement of the late Prof. Elliot upon the instrument of 
Simpson consists in narrowing and lengthening the shanks, widening 
somewhat the fenestra?, elongating the blades, giving greater security 
against slipping in the handles, and ganging the distance between the 
blades by a milled-head screw-stop in the end of the handles ; the 
shanks and blades are an exact counterpart of the Miller forceps of 
England, which appeared about the same time (1858). 

The Hodge forceps was based in its contrivance upon the following 
points: 1. The instrument should be shaped to the contour of the 
foetal head, and have sufficient play to allow of compression where the 
pelvis is too narrow for the head to pass in its normal condition. 
2. The blades should be so arranged in reference to the shanks and 
handles as to enable them to seize the head of the foetus in its bi-parietal 
diameter at the superior strait, and be drawn upon in the direction of 
the curve of the pelvic canal until the delivery is complete. 3. The 
long forceps ought to be competent to act either at the superior strait 
of the pelvis, in its cavity, or at its outlet, so as to avoid a multiplicity 
of instruments and their attendant expense. And, 4. The instru- 
ment should not cut the scalp of the child if properly adjusted, or 
injure the soft parts of the mother. 

It would be folly to claim that all this could be or has been accom- 

r 1 Obstetrics, p. 540.] 

[ 2 The Simpson forceps, and the method of application in reference to the pelvis instead of the 
head, appear to be growing very largely in favor in America.— Ed. J 



512 



OBSTETRIC OPERATIONS 



piished, as there must necessarily be exceptional cases in all the points 
given ; hence the contrivance of the forceps of Tarnier and Cleemann 
for certain presentations above the superior strait, and the long and 
short convertible instruments of a few inventors. There are many 
cases of labor in the higher walks of life where, although there is no 
obstruction, still the women require manual or instrumental assistauce, 
as they cannot deliver themselves for want of sufficient contractile 
muscular force. Such women require that the forceps used should be 



Fig. 177. 



Fig. 17S. 



Fig. 179. 




Hodge forceps. 



Wallace forceps. 



Davis forceps. 



easily introduced — should act simply as tractors, control the movement 
of the foetal head by being well fitted to its shape, and leave no effect 
upon the scalp or vulva. Although these requisites may be filled by 
the Hodge instrument, it is this class of cases that has demanded a 
lighter and more roomy pair of forceps, such as that devised by Davis. 
As the teaching of the Jefferson Medical College under Dr. Meigs 
favored, as we have stated, the forceps of Davis, so his successor, Prof. 
AVallace, in carrying out in a measure the same views, combined the 
blades of the Davis pattern with the long handles of Hodge in con- 
triving what is known as the " Wallace forceps. " As compared with 



THE FORCEPS. 513 

the Hodge instrument, it is one inch shorter (fifteen inches against 
sixteen) ; the blades are of the same length (six inches) ; the fenestra 
are more open ; the shanks are only half the length, giving much 
greater compressing power ; and the handles are of the same measure- 
ment from pivot to hooks. Both have the Siebold lock, over which 
we believe the broad-topped button and notch to possess some advan- 
tages ; and the Wallace is somewhat heavier than the Hodge, which 
should weigh seventeen ounces. 

The short Davis instrument made for Prof. Meigs under direction 
of the inventor weighed ten and three-quarters ounces and measured 
twelve inches in length ; fenestra, five inches long, two inches wide ; 
blades separated two and three-quarters inches ; handles, four and one- 
quarter inches to lock, which was of the Smellie or English pattern. 
A pair in possession of the editor is thirteen and one-half inches long, 
with five-inch handles, a button lock, two-inch close-set shanks, and 
six and one-half inch blades. I believe the changes are decided im- 
provements, especially the lock and elongated handles. It has answered 
admirably in adynamic cases requiring only a few pounds of tractile 
assistance. The Davis blades have been added to long handles, and 
the whole made of steel and marvellously light, at the special request 
of a few accoucheurs, who wished them to aid in some cases of arrest 
at the perineum. 

The late Prof. George T. Elliot, of New York, who received much 
of his practical obstetrical training in the Dublin Lying-in Hospital, 
imbibed the teachings of the English school, and became impressed 
with the value of the system as taught by Simpson, upon the principle 
of whose forceps, modelled somewhat after that of the late Prof. Gun- 
ning S. Bedford, of New York, he in 1858 presented to the medical 
profession the instrument that bears his name. The forceps of Prof. 
Bedford has a traction-ring on each side where the Elliot has a cornu, 
has a button joint instead of a Smellie, has no screw top, and has 
diverging instead of superimposed shanks ; these points have generally 
been considered as improvements. 

The Sawyer Forceps. — This is the lightest of all the varieties of 
the short forceps, weighing but five ounces, and measuring nine and 
three-quarters inches in length ; the handle being three inches, shank 
one and a half, and chord of blade-curve five and a quarter. The 
blades are one and a half inches wide, with oval fenestras seven-eighths 
of an inch w T ide, and separated two and five-eighths inches at their 
widest part and three-quarters of an inch at the tips. This instrument 
was invented twelve years ago by Pro£ Edw. Warren Sawyer, of 
Rush Medical College, Chicago, and has been highly commended by 
Prof. By ford and others. The forceps has the blades of Davis, super- 
imposed shanks of Hodge, and lock of Smellie, with hard-rubber plates 
moulded hot upon the handles. The several parts have been some- 
what modified, the object being to secure a tractor for cases of deficient 
expulsive force where the foetal head is low in the pelvis. 

Professor Sawyer says : " In the labors to which my forceps is 
applicable it is not necessary for the operator's body to be in line with 
the pelvic axis. My mode of procedure is the following: The woman 

33 



514 



OBSTETRIC OPERATIONS. 



is placed upon her back and drawn to the edge of the bed ; the outside 
leg is now flexed ; beneath this flexed extremity and the bed-covering 
I apply the forceps — often using but one hand in the operation. When 
the instrument is locked, I grasp the handle in such a manner that 
the palm of the hand looks upward ; one hook then rests naturally 
upon the extensor surface of the first phalanx of the index finger, 
while the other hook rests upon a corresponding part of the thumb. 
When thus adjusted, I lift the head from the pelvic outlet, at the 
same time invoking the pendulum movement if desired. At this 



Fig. 180. 



Fig. 181. 




Elliot forceps. 



Sawyer forceps. 



moment the advantage of the hooked handle is very apparent to the 
operator." . . . "All practitioners must have often felt, during 
the last moments of labor, when the uterus and the mother seemed 
fatigued, the need of a little help to the expulsive powers. The ordi- 
nary instruments are too formidable to be used at the last moment, and 
it is then that this little forceps is useful." 

The mechanism of instrumental delivery is much simplified by 
applying the forceps to whatever parts of the foetal head may be oppo- 
site the sides of the pelvis, but it is very questionable whether it is the 
scientific method or the safer for the child. With one blade over the 
side of the occiput, and the other over that of the forehead — which is 



THE FORCEPS. 515 

the manner of seizure in oblique positions of the vertex — we certainly 
have not a very secure hold and run some risk of injury to the foetus. 
The advocates of this system claim that they use no compression, only 

a simple traction ; which may he true in one sense, hnt amounts to the 
same in effect, else how could Dr. Elliot, by traction with great force, 
straighten out one of the blades of his Simpson forceps, as related in 
the New York Journal of Medicine for September, 1858, p. 161, in the 
paper which he presented describing his new forceps and a number of 
cases in which lie had tested them ? It makes but little difference 
whether we compress the head before we begin to pull, or pull so as to 
wedge the head between the blades, and thus compress it, except as to 
the difference of fit in the two instances ; the adjusted and even pressure 
being the less likely to injure the foetus. I have always believed that 
the forceps should fit the head, and that the student should be taught 
how to accomplish it correctly in the various positions of the foetus. 
If the student has a mechanical turn of mind, a delicate sense of touch, 
and a clear head, he will soon learn ; if he is not a mechanic, he will 
be forced to adopt a more simple method of delivery. In a large city 
there are but few first-class obstetrical manipulators as a general rule, 
and they are usually well known as such, for the reason that but few 
have all the requisites to enable them to achieve notoriety ; and yet 
there are hundreds who can deliver a woman with forceps moderately 
well. To one the mechanism of Hodge is a simple matter and soon 
mastered ; to another it is a useless complication, and he prefers the 
more simple system. Hence the great differences between obstetricians 
as to the best instrument and the best method of application. Some 
of the vast array of patterns have decided merit and display much 
mechanical skill, while others serve only to amuse the educated ex- 
aminer. One obstetrician, after the manner of Elliot, uses a variety 
of forceps one after another in the case, and pulls with great force, 
while another confines his work almost to one instrument, adjusts it 
easily, pulls moderately, and seldom fails. There are no doubt excep- 
tions, but certainly the most delicate manipulators we have seen 
believed in and practised the teachings of Hodge and Meigs. There 
may be cases where it might be well to practise the method of Simpson, 
but we cannot see why his plan of delivery should be exclusively used 
on any mode of scientific reasoning. 

I present a series of illustrations showing the American method of 
delivery with the forceps, the position, as will be seen, being that of 
France and Germany — on the back. When it is decided to use the 
forceps, in almost all cases in the United States the patient is brought 
to the edge of the bed on her back, with her nates close to the edge, 
her feet on two chairs, and her knees widely separated, as in the illus- 
tration. The patient is covered with a sheet, or with a heavier cover- 
ing if in winter, and there is no necessity of exposure, as the whole 
manipulation may be done by the sense of touch. The position is by 
far the most convenient for the obstetrician, and enables him much 
more easily to keep in his mind all the anatomical relations of the 
foetus and pelvis than when in the English decubitus. We study the 
anatomy with the subject on the back, and the mechanism of labor in 



516 



OBSTETRIC OPERATIONS. 



front of the pelvis or manikin ; then why complicate matters by a 
change of position, which, to say the least, is a very awkward one, 
particularly in introducing the long forceps, setting it according to the 
instructions of Hodge, and carrying it forward between the thighs as 
the head emerges ? I have used the short forceps in an exhausted case 
with the woman on her side, but found it much less convenient for the 
various movements, although I soon delivered the foetus. As to the 
question of exposure, there is less in appearance than, in fact, in the 



Fig. 182. 




Application of the forceps at the inferior strait. 



English position in many cases. If the patient and nurse are fastidi- 
ous and careful during the use of the forceps, the accoucheur can 
manage without his eyes in a large proportion of cases ; but the fault 
of exposure lies more frequently in the temporary reckless indifference 
begotten of pain and suffering in the woman, than in any act of the 
accoucheur if inclined to spare the feelings of his patient as much as 
possible. 

The long forceps, with its pelvic curve, was specially designed for 
use at the superior strait of the pelvis, the curve of the blades, as in 



THE FORCEPS 



517 



the Davis instrument modified by Wallace, being intended to corre- 
spond with the direction of the occipito-mental diameter of the foetal 
head. The long superimposed shanks of several varieties of the long 
forceps will here be found valuable, as the lock is not introduced or 
the posterior commissure of the vulva widely stretched. If the head 
is entirely above the strait, the line of the blades must be changed 



Fig. 183. 




Application of the forceps with the head at the superior strait, the left blade held in place 

oy an assistant. 



line 



correspondingly, in order to apply them properly and keep the 
of traction within the coccyx ; and even then, to draw in the proper 
direction, the left hand must act at first in a backward direction from 
the lock, while the right brings the handles downward, forward, and 
then upward ; both hands describing a curve, but that of the right 
being much the greater. The peculiar forceps of Tarnier, Poullet, 
and Cleemann, being designed to meet this form of exigency, may be 
brought into recpiisition. 



518 



OBSTETRIC OPERATIONS. 



In latter years it has become much more common than formerly to 
introduce the forceps into the uterus before it is fully dilated, in conse- 
quence of the success claimed for the plan as carried out in the Dublin 
Lying-in Hospital. As this should never be done where the os is not 
readily dilatable, and requires much skill in execution, it is not safe to 
recommend its general adoption in cases of delay in private practice. 

The forceps should not be introduced with any force, but the left 
blade should be slid in gently and with a spiral motion, and then the 
right, care being taken that they should also lock without force, which 



Fig. 184. 




Direction of the forceps as the head is being delivered. 

they will do if properly adjusted. Traction is to be exerted slowly and 
during a pain, the whole movement being made to correspond with the 
natural one as closely as possible. 

As the foetal head comes under the arch of the pubes the handles of 
the forceps must rise more and more from the bed, until at last they 
are over the abdomen as the head emerges from the perineum. This 
last movement of instrumental delivery should be a very slow one, for 
fear of rupture. It has been proposed to remove the blades before 
delivery is complete ; but there is no occasion for this if the forceps is 
applied to the sides of the head over the parietal protuberances, as, 
where these protrude and the blades are flat and thin, there is very 
little additional space required. With such instruments as the old 



THE VECTIS. — THE FILLET. 519 

Levret, Baudelocque, and Rohrer forceps, with looped or kite-shaped 
fenestra and thick edges, this was a much more ■ imperative direction 
than with the better instruments of the present day. With a Sawyer 
forceps the perineum ought to be safer and under better control than 
without. When the perineum is thought to be in danger, the process 
of distention should be retarded through two or three pains, or even 
more if required, instead of drawing the head through at once. 

After the head is delivered, if the cord is not around the neck and 
therefore in danger from pressure, the body should be allowed to 
remain until the uterus has well contracted upon it, for fear of hemor- 
rhage after delivery, from uterine inertia. — Ed.] 



CHAPTEK IY. 

THE VECTIS.— THE FILLET. 

The Vectis. — In connection with the subject of instrumental de- 
livery, it is essential to say something of the use of the vectis, on 
account of the value which was formerly ascribed to it, which was at 
one time so great in England that it became the favorite instrument 
in the metropolis ; Denman saying of it that even those who employed 
the forceps were " very willing to admit the equal, if not superior, 
utility and convenience of the vectis/' Even at the present day there 
are practitioners of no small experience who believe it to be of occasional 
great utility, and use it in preference to the forceps in cases in which 
slight assistance only is required. In spite, however, of occasional 
attempts to recommend its use, the instrument has fallen into disfavor, 
and may be said to be practically obsolete. 

Nature of the Instrument. — The vectis, in its most approved form, 
consists of a single blade, not unlike that of a short straight forceps, 
attached to a wooden handle. A variety of modifications exists in its 
shape and size. The handle has been occasionally manufactured; for 
the convenience of carriage, with a hinge close to the commencement 
of the blade (Fig. 185), or with a screw at the point where the handle 
and blade join. The power of the instrument, and the facility of 
introduction, depend very much on the amount of curvature of the 
blade. If this be decided, a firmer hold of the head is taken and 
greater tractile force is obtained, out the difficulty of introduction is 
increased. 

When employed in the former way, the fulcrum is intended to be 
the hand of the operator ; but the risk of using the maternal structures 
as sl point d'appui, and the inevitable danger of contusion and lacera- 
tion which must follow, constitute one of the chief objections to the 
operation. Its value as a tractor must always be limited and quite 



520 



OBSTETEIC OPERATIONS. 



inferior to that of the forceps, while it is as difficult to introduce and 
manipulate. 

Cases in -which it is Applicable. — The vectis has been recom- 
mended in cases in which the low forceps operation is suitable, pro- 
vided the pains have not entirely ceased. There is no doubt that it 
may be quite capable of overcoming a slight impediment to the passage 
of the head. It is applied over various parts of the head, most com- 
monly over the occiput, in the same manner, and with the same 
precautions, as one blade of the forceps. Dr. Ramsbotham says : " AVe 
shall find it necessary to apply it to different parts of the cranium, and 
perhaps the face also, successively, in order to relieve the head from 
its fixed condition and favor its descent." Such an operation ob- 
viously requires quite as much dexterity as the application of the 
forceps ; while, if we bear in mind its comparatively slight power and 
the risk of injury to the maternal structures, we must admit that the 
disuse of the instrument in modern practice is amply justified. 



Fig. 186. 



Fig. 1S5. 




Yectis with hinged handle. 



Wilmot's fillet. 



The vectis may, however, find a useful application when employed 
to rectify malpositions, especially in certain occipito-posterior presenta- 
tions. This action of the instrument has already been considered (page 
334), and, under such circumstances, it may prove of service where the 
forceps is inapplicable. AVhen so employed it is passed carefully over 
the occiput, and, while the maternal structures are guarded from injury, 
downward traction is made during the continuance of a pain. So 
used, its application is perfectly simple and free from danger, and for 
this purpose it may be retained as part of the obstetric armamen- 
tarium. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 521 

The Fillet is the oldest of obstetric instruments, having been fre- 
quently employed before the invention of the forceps, and even in the 
time of Smellie it was much used in the metropolis. It has since com- 
pletely fallen out of favor as a scientific instrument, although its use is 
every now and again advocated, and it is certainly a favorite instru- 
ment with some practitioners. This is to he explained by the apparent 
simplicity of the operation, and the fact that it can generally he per- 
formed without the knowledge of the patient. The latter, however, is 
one strong reason why it should not be used. 

Nature of the Instrument. — The fillet consists, in its most im- 
proved form (that which is recommended by Dr. Eardley Wilmot 1 ) 
(Fig. 186), of a slip of whalebone fixed into a handle composed of 
two separate halves which join into one. The whalebone loop is 
slipped over either the occiput or face, and traction used at the 
handle. [ 2 ] 

When applied over the face, after the head has rotated, it would 
probably do no harm ; but if it were so placed when the head was 
high in the pelvis, traction would necessarily produce extension of the 
chin before the proper time, and would thus interfere with the natural 
mechanism of delivery. If placed over the occiput, it is impossible 
to make traction in the direction of the pelvic axes, as the instrument 
will then infallibly slip. If traction be made in any other direction, 
there must be a risk of injuring the maternal structures, or of changing 
the position of the head. Hence there is every reason for discarding 
the fillet as a tractor, or as a substitute for the forceps, even in the 
simplest cases. 

It is quite possible that it may find a useful application in certain 
cases in which the vectis may also be used, viz., as a rectifier of mal- 
position ; and, from the comparative facility of its introduction, it 
would probably be the preferable instrument of the two. 



CHAPTER Y. 

OPEEATIOXS INVOLVING DESTKUCTIOX OF THE FCETUS. 

Operations involving- the destruction and mutilation of the 
child Mere among the first practised in midwifery. Craniotomy was 
evidently known in the time of Hippocrates, as he mentions a mode 
of extracting the head by means of hooks. Celsus describes a similar 
operation, and was acquainted with the manner of extracting the foetus 
in transverse presentations by decapitation. Similar procedures were 

1 Obst. Trans.. 1^74. vol. xv. p. 172 

[ 2 The whalebone fillet originated with the Japanese, and was a fearfully destructive instrument 
with them, traction being made with a windla-s.— Ed.] 



522 OBSTETEIC OPERATIONS. 

also practised and described by Aetius and others among the ancient 
writers. The physicians of the Arabian school not only employed 
perforators for opening the head, but were acquainted with instru- 
ments for compressing and extracting it. 

Religious Objections to Craniotomy. — Until the end of the seven- 
teenth century this class of operation was not considered justifiable in 
the case of living children ; it then came to be discussed whether the 
life of the child might not be sacrificed to save that of the mother. 
It was authoritatively ruled by the Theological Faculty of Paris that 
the destruction of the child in any case was mortal sin. "Si Ton ne 
pent tirer l'enfant sans le tuer, on ne peut sans p6che mortel le tirer." 
This dictum of the Roman Church had great influence on Continental 
midwifery, more especially in France, where, up to a recent date, the 
leading obstetricians considered craniotomy to be only justifiable when 
the death of the foetus had been positively ascertained. Even at the 
present day there are not wanting practitioners who, in their praise- 
worthy objection to the destruction of a living child, counsel delay 
until the child has died — a practice thoroughly illogical, and only 
sparing the operator's feelings at the cost of greatly increased risk to 
the mother. In England the safety of the child has always been con- 
sidered subservient to that of the mother ; and it has been admitted 
that, in every case in which the extraction of a living foetus by any 
of the ordinary means is impossible, its mutilation is perfectly justi- 
fiable. 

Formerly Performed with Unjustifiable Frequency. — It must be 
admitted that the frequency with which craniotomy has been performed 
in England constitutes a great blot on British midwifery. During 
the mastership of Dr. Labbat, at the Rotunda Hospital, the forceps 
was never once applied in 21,867 labors. Even in the time of Clarke 
and Collius, when its frequency was much diminished, craniotomy was 
performed three or four times as often as forceps delivery. These figures 
indicate a destruction of foetal life which we cannot look back to without 
a shudder, and which, it is to be feared, justify the reproaches which 
our Continental brethren have cast upon our practice. Fortunately, 
professional opinion has now completely recognized the sacred duty of 
saving the infant's life Avhenever it is practicable to do so; and British 
obstetricians now teach as carefully as those of any other nation the 
imperative necessity of using every endeavor to avoid the destruction 
of the foetus. 

Divisions of the Subject. — The operation now under consideration 
may be necessary : 1st, when the head requires either to be simply 
perforated, or afterward more completely broken up and extracted — 
an operation which has received various names, but is generally known 
in England as craniotomy, and which may or may not require to be 
followed by further diminution of the trunk ; 2d, when the arm pre- 
sents, and turning is impossible. This necessitates one of two pro- 
cedures — decapitation, with the separate extraction of the body and 
head, or evisceration. In both classes of cases similar instruments are 
employed, and those generally in use at the present time may be first 
briefly described. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 523 



Instruments Employed. — The object of the 'perforator is to pierce 
the skull of the child, so as to admit of the brain being broken up 
and the consequent collapse and diminution in size of the cranium. 
The perforator invented by Dennian, or some modification of it, has 
been principally employed. It requires the handles to be separated in 
order to open the blades, and this cannot be done by the operator him- 
self. This difficulty is overcome in the modification of Naegele's 
perforator used in Edinburgh, in which the handles are so constructed 
that they open the points when pressed together, and are separated by 
a steel rod with a joint at its centre to prevent their opening too 
soon. By this arrangement the instrument can be manipulated by one 
hand only. The sharp-pointed portion has an external cutting edge, 
with projecting shoulders at its base to prevent its penetrating too far 



Fig. 187. 



Fig. 188. 



Fig. 189. 




Various forms of perforators. 



into the cranium. Many modifications of these arrangements have 
since been contrived (Figs. 187, 188, 189). In some parts of the 
Continent a perforator is used constructed on the principle of the 
trephine ; but this is vastly more difficult to work and has the great 
disadvantage of simply boring a hole in the skull, instead of splitting 
it up, as is done by the sharp-pointed instrument. 

The instruments for extraction are the crotchet and craniotomy 
forceps. 

Crochets and Craniotomy Forceps. — The crotchet is a sharp- 
pointed hook of highly tempered steel, which can be fixed on some 
portion of the skull, either internal or external, traction being made 
by the handle. The shank of the instrument is either straight or 
curved (Figs. 190 and 191), the latter being preferable, and it is either 
attached to a wooden handle or forged in a single piece of metal. A 
modification of this instrument is known as Oldham's vertebral hook. 
It consists of a slender hook, measuring with its handle thirteen 



524 



OBSTETRIC OPERATIONS, 



Figs. 190, 191. 



inches in length, which is passed through the foramen magnum and 
fixed in the vertebral canal, so as to secure a firm hold for traction. 
All forms of crotchets are open to the serious objection of being liable 
to slip, or break through the bone to which they 
are fixed, so wounding either the soft parts of the 
mother, or the fingers of the operator placed as a 
guard. Hence they are discountenanced by most 
recent writers, and may with propriety be regarded 
as obsolete instruments. 

Their place as tractors is well supplied by the 
more modern craniotomy forceps (Fig. 192). These 
are intended to lay hold of the skull, one blade 
being introduced within the cranium, the other ex- 
ternally, and, when a firm grasp has been obtained, 
downward traction is made. A second object it 
fulfils is to break away and remove portions of the 
skull when perforation and traction alone are insuffi- 
cient to effect delivery. Many forms of craniotomy 
forceps are in use — some armed with formidable 
teeth; others, of simpler construction, depending 
on their roughened and serrated internal surfaces 
for firmness of grasp. For general use, there is 
no better instrument than the cranioclast of Sir 
James Y. Simpson (Fig. 193), which admirably 
fulfils both these indications. It consists of two 
separate blades fastened by a button joint. The 
extremities of the blades are of a duck-billed shape, 
and are sufficiently curved to allow of a firm grasp 
of the skull being taken : the upper blade is deeply 
grooved to allow the lower to sink into it, and this gives the instru- 
ment great power in fracturing the cranial bones, when that is found 
to be necessary. It need not, however, be employed for the latter 
purpose ; and the blades, being serrated on their under surface, form 
as perfect a pair of craniotomy forceps as any in ordinary use. Pro- 
vided with it, we are spared the necessity of procuring a number of 
instruments for extraction. 

Cephalotribe. — Amongst modern improvements in midwifery there 
are few which have led to more discussion than the use of the cephalo- 
tribe. This instrument, originally invented by Baudelocque, w r as long 
employed on the Continent before it was used in England, the prej Li- 
dice against it being no doubt due to its formidable size and appear- 
ance. [ x ] Of late years many of our leading obstetricians have used 
it in preference to either the crotchet or craniotomy forceps, and have 
materially modified and improved its construction, so that the most ob- 
jectionable features of the older instruments are now entirely removed. 
The cephalotribe consists of two powerful solid blades, which are 
applied to the head after perforation, and approximated by means of a 
screw so as to crush the cranial bones, and after this it may also be 



Crotchets. 



t 1 It was introduced into our country in 1S43, under the name of brise-t'te.— Ed.] 



OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 525 

used for extraction. The peculiar value of the instrument is that, 
when properly applied, it crushes the firm base of the skull, which is 
left untouched by craniotomy ; or, if it does not, it at least causes the 
base to turn edgewise within the blades, so as to be in a more favorable 
position for extraction. Another and specially valuable property is 
that it crushes the bones within the scalp, which forms a most efficient 
protective covering to their sharp edges. In this way one of the 
principal dangers of craniotomy — the wounding of the maternal pas- 
sages by spiculse of bone — is entirely avoided. 



Fig. 192. 



Fig. 193. 





Craniotomy forceps. 



Simpson's cranioclast. 



The cephalotribe, therefore, acts in two w r ays — as a crusher and as 
a tractor. Some obstetricians believe the former to be its more im- 
portant use, and even maintain that the cephalotribe is unsuited for 
traction. This view is specially maintained by Pajot, who teaches 
that, after the size of the skull has been diminished by repeated 
crushings, its expulsion should be left to the natural powers. There 
are some grounds for believing that in the greater degrees of obstruc- 
tion the tractile power of the instrument should not be called into use ; 
but, in the large majority of cases, the facility with which the crushed 
head may be withdrawn by it constitutes one of its chief claims to the 
attention of the obstetrician. IN'o one who has used it in this way, 
and experienced the rapid and easy manner in which it accomplishes 
delivery, can have any doubt on this point. 

There is every reason to believe that cephalotripsy will be much 
extended in Great Britain, and that it will be considered, as I believe 
it unquestionably deserves to be, the ordinary operation in cases re- 
quiring destruction of the foetus. [ x ] The comparative merits of cephalo- 
tripsy and craniotomy will be subsequently considered. 



[! This is certainly not its future in the United States, where foetal destruction is heing avoided, 
under the largely diminished fatality of the Csesarean section and symphyseotomy.— Ed.] 



526 



OBSTETKIC OPERATIONS. 



The most perfect cephalotribe is probably that known as Braxton 
Hicks^s (Fig. 194), which is a modification of Simpson's. It is not 

of unwieldy size, but sufficiently pow- 
fig. 194. erful for any case, and not extravagant 

in price. The blades have a slight 
pelvic curve, which materially facili- 
tates their introduction, yet not suffi- 
ciently marked to interfere with their 
being slightly rotated after application. 
Dr. Kidd, of Dublin, prefers a straight 
blade ; while Dr. Matthews Duncan 
thought it better to use a somewhat 
bulkier instrument, modelled on the 
type of the Continental cephalotribes. 
The principle of action of all these is 
identical, and their differences are not 
of very material importance. 

Section of the Skull by the For- 
ceps-saw, or Ecraseur. — Another 
mode of diminishing the foetal skull 
is by removing it in sections. The 
object is aimed at in the forceps-saw 
of Van Huevel, which consists of two 
large blades, not unlike those of the 
cephalotribe in appearance. Within 
these there is a complicated mechanism,, 
working a chain-saw from below up- 
ward, which cuts through the foetal 
skull ; the separated portions are sub- 
sequently withdrawn piecemeal. This 
instrument is highly spoken of by the 
mcks's cephalotribe. Belgian obstetricians, who believe that 

it affords by far the safest and most 
effectual way of reducing the bulk of the foetal skull. A somewhat 
similar instrument has been invented by Tarnier. In Great Britain 
these instruments are practically unknown ; and, although they must 
be admitted to be theoretically excellent, the complexity and cost of 
the apparatus have always stood in the way of their being used. 

Dr. Barnes has suggested that the same results may be obtained by 
dividing the head with a strong wire ecraseur. So far as I know, this 
suggestion has never yet been carried out in practice, not even by 
himself, and therefore it is not possible to say much about it. I 
should imagine, however, that there would be considerable difficulty 
in satisfactorily passing the loop of wire over the skull in a pelvis in 
which there is any well-marked deformity. 

Cases requiring' Craniotomy. — The most common cause for which 
craniotomy or cephalotripsy is performed is a want of proper propor- 
tion between the head and the maternal passages. This may arise 
from a variety of causes. The most important, and that most often 
necessitating the operation, is osseous deformity. This may exist 




OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 527 

either in the brim, cavity, or outlet, and it is most often met with in 
the antero-posterior diameter of the brim. Obstetric authorities differ 
considerably as to the precise amount of contraction which will pre- 
vent the passage of a living child at term. Thus Clarke and Burns 
believe that a living child cannot pass through a pelvis in which the 
antero-posterior diameter at the brim is less than three and one-quarter 
inches. Ramsbotham fixes the limit at three inches, and Osborne and 
Hamilton at two and three-quarters inches. The latter is the extreme 
limit at which the birth of a living child is possible; but there can 
be no doubt that, under favorable circumstances, it may be possible to 
draw the foetus, after turning, through a pelvis of that size. The 
opposite limit of the operation is still more open to discussion. Various 
authorities have considered it quite possible to draw a mutilated foetus 
through a pelvis in which the antero-posterior diameter does not exceed 
one and one-half inch, and, indeed, have succeeded in doing so. But 
then there must be a fair amount of space in the transverse diameter 
of the pelvis to admit of the necessary manipulations. If there be a 
clear space here of three inches and upward, it is no doubt possible to 
deliver per vias naturales ; but in such extreme deformities, the diffi- 
culties are so great, and the bruising of the maternal structures so 
extensive, that it becomes an operation of the greatest possible severity, 
with results nearly as unfavorable to the mother as the Csesarean 
section. [*] Hence some Continental authorities have not scrupled to 
prefer the latter operation in the worst forms of pelvic deformity. The 
rule in English practice always has been that craniotomy must be per- 
formed whenever it is practicable ; and there can be no doubt that it 
is, generally speaking, the right one. 

Between from two and three-quarters to three inches antero-posterior 
diameter in the one direction, and one and three-quarters inches in the 
other, may be said to be the limits of craniotomy, provided, in the 
latter case, there be a fair amount of space in the transverse diameter. 
The same limits may be laid down with regard to tumors or other 
sources of obstruction. 

There are a few other conditions in which craniotomy is justifiable, 
independently of pelvic contraction, such as certain conditions of the 
soft parts which are supposed to render the passage of the head pecu- 
liarly dangerous to the mother. Among them may be mentioned 
swelling and inflammation of the vagina from the length of the pre- 
vious labor, bands and cicatrices of the vagina, and occlusion and 
rigidity of the os. It is hardly too much to say that with a proper 
use of the resources of midwifery, the destruction of a living foetus 
for any of these conditions might be obviated. The most common of 
them is undoubtedly swelling of the soft parts causing impaction of 
the head, an occurrence which ought to be invariably prevented by 
a timely use of the forceps. Should interference unfortunately be 
delayed until impaction has actually taken place, doubtless no other 
resource but craniotomy would be left ; but such cases, it is to be 
hoped, are now of rare occurrence in British practice. Undue rigidity 

P The experience of our country indicates that in extreme pelvic deformity the conservative 
Caesarean section has the less risk of the two.— Ed. 1 



528 OBSTETRIC OPERATIONS. 

of the os can be overcome by dilatation with the caoutchouc bags, or, 
in more serious cases, by incision, which would certainly be less 
perilous to the mother than dragging even a mutilated foetus through 
the small and rigid aperture. In the case of bands and cicatrices in 
the vagiua, dilatation or incision will generally suffice to remove the 
obstruction ; but even were this not so here, as in excessive rigidity of 
the perineum, it would be better that slight lacerations should take 
place than that the child should be killed. 

Certain complications of labor are held to justify craniotomy, 
such as rupture of the uterus, convulsions, and hemorrhage. The 
application of the forceps or turning will generally answer our purpose 
equally well, especially as we have the means of dilating the os suffi- 
ciently to admit of one or other of them being performed when the 
natural dilatation is not sufficient. Craniotomy in rupture of the 
uterus will also be rarely indicated, as we have seen that coeliotomy 
appears to afford a better chance to the mother in those cases in 
which the foetus has partially or entirely escaped from the uterine 
cavity. 

Want of proportion between the foetus and the pelvis, depending on 
undue size of the head, either natural or the result of disease, may 
render the operation essential. In the former of these cases we shall 
generally have first attempted delivery with the forceps, and, if it has 
failed, there can be no doubt as to the propriety of lessening the bulk 
of the head by perforation, unless we determine to attempt delivery by 
symphyseotomy (see p. 557). 

In most obstetric works we are recommended to perforate rather 
than apply the forceps, when we are convinced that the child has 
ceased to live. This advice is based on the greater facility with which 
craniotomy can be performed, and its supposed greater safety to the 
mother. There can be no doubt of the ease with which the child can 
be extracted after perforation, when the pelvis is not contracted ; and, 
if we could always be sure of our diagnosis, the rule might be a good 
one. Before acting on it, however, we must bear in mind the extreme 
difficulty of positively ascertaining the death of the foetus. Of the 
signs usually relied on for this purpose, there are scarcely any which 
lire not open to fallacy, except peeling of the scalp, and disintegration 
of the cranial bones, which do not take place unless the child has been 
dead for a length of time, and are, therefore, useless in most instances. 
Discharge of the meconium constantly takes place when the child is 
alive ; a cold and pulseless prolapsed cord may belong to a twin ; and 
a foetal heart may become temporarily inaudible, although the child is 
not dead. If, indeed, we have carefully watched the foetal heart all 
through the labor, and heard it become more and more feeble, and 
finally stop altogether, we might be certain that the child has died ; 
but surely such observations would rather indicate an early recourse 
to the forceps or version, so as to obviate the fatal result we know to 
be impending. 

Perforation of the After-coming- Head. — In certain breech pres- 
entations, or after turning, it may be found impossible to extract the 
head without diminishing its size by perforating behind the ear. In 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 529 

such cases we know to a certainty whether the child be alive or dead, 
before resorting to the operation. 

The preliminary step, whether we resort to omphalotripsy or crani- 
otomy, is perforation, which will, therefore, be first described. In the 
former the desirability of first perforating the head is not always 
recognized. To endeavor to crush the nead without perforating is 
needlessly to increase the difficulties of the case, and it should be 
remembered, as a cardinal rule, that perforation is an essential pre- 
liminary to the proper use of the cephalotribe. 

Fig. 195. 




Perforation of the skull. 



Before perforating we must carefully ascertain the exact relation of 
the os to the presenting part, since, in many cases, the operation is 
performed before the os is fully dilated, when there is a risk of wound- 
ing the cervix. Two or more fingers of the left hand should be passed 
up to the head and placed against the most prominent part of the 
parietal bone. Under these, used as guard (Fig. 195), the perforator 
should be cautiously introduced until the scalp is reached. It is im- 
portant to fix on a bony part of the skull, and not on a suture or 
fontanelle, for puncture, because our object is to break up the vault of 
the cranium as much as possible, so as to allow the skull to collapse. 
When the instrument has reached the point we have selected, it should 
be made to penetrate the scalp and skull with a semi-rotatory boring 

34 



530 OBSTETRIC OPERATIONS. 

motion, and advanced until it has sunk up to the rests, which will 
oppose its further progress. Occasionally considerable force will be 
necessary to effect penetration, more especially if the scalp be swollen 
by long-continued pressure ; and this stage of the operation will be 
facilitated by causing an assistant to steady the head by pressure on 
the foetus through the abdomen, more especially if it be still free above 
the pelvic brim. "We must then press together the handles of the 
instrument, which will have the effect of widely separating the cutting 
portion, and making an incision through the bones. After this the 
point should be turned around, and again opened at right angles to 
the former incision, so as to make a free crucial opening. During this 
process care must be taken to bury the perforator in the skull up to 
the rests, so as to avoid the possibility of injuring the maternal soft 
parts. The instrument should now be introduced within the skull 
and moved freely about, so as to thoroughly and completely break up 
the brain. Especial care must be taken to reach the medulla oblongata 
and base of the brain, for, if these are not destroyed, we might subject 
ourselves to the distress of extracting a child in whom life was not 
extinct. If this part of the operation be thoroughly performed, there 
will be no necessity for washing out the brain by the injection of warm 
water, as is sometimes recommended, for the broken-up tissue will 
escape freely through the opening made by the perforator. 

The perforation of the after-coming head does not generally offer 
any particular difficulty. It is accomplished in the same manner, the 
child's body being well drawn out of the way by an assistant. The 
point of the perforator, carefully guarded by the finger, is guided up 
to the occiput, or behind the ear, where it is inserted, or perforation 
may be performed through the hard palate. 

If there be no necessity for very rapid delivery, and the pains be 
still present, it is often advisable to wait ten minutes or a quarter of 
an hour before proceeding to extract. This delay will allow the skull 
to collapse and become moulded to the cavity of the pelvis, when forced 
down by the pains, and possibly the natural efforts may suffice to finish 
the labor in that time ; or, at least, the head will have descended 
further, and will be in a better position for extraction. Should per- 
foration be required after having failed to deliver with the forceps — 
and this is only likely to be the case when the obstruction is com- 
paratively slight — it is certainly a good plan to perforate without 
removing the forceps, which may then be used as tractors. 

We have now to decide on the method of extraction, and our choice 
generally lies between the cephalotribe and the craniotomy forceps, 
although in some few cases, in which the pelvic contraction is slight, 
version may be advantageously employed. Some have even advised 
version as a preliminary step in all cases requiring craniotomy, the 
skull being perforated through the roof of the mouth, and subsequently 
crushed with the cephalotribe. 1 

Comparative Merits of Cephalotripsy and Craniotomy. — Those 
who have used both must, I think, admit that in any ordinary case, in 

1 See Donald on " Methods of Craniotomy," Obst. Trans., vol. xxxi. p. 28. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 531 

which the obstruction is not great, and only a comparatively slight 
diminution in the size of the head is required, cephalotripsy is infi- 
nitely the easier operation. The facility with which the skull can be 
crushed is sometimes remarkable, and those who will take the trouble 
to read the reports of the operation published by Braxton Hicks, Kidd, 
and others, cannot fail to be struck with the rapidity with which the 
broken-down head may often be extracted. This is far from being the 
case with the craniotomy forceps, even when the obstruction is moder- 
ate only; for it may be necessary to use considerable traction, or the 
blades may take a proper grasp with difficulty, or it may be essential 
to break down and remove a considerable portion of the vault of the 
cranium before the head is lessened sufficiently to pass. During the 
latter process, however carefully performed, there is a certain risk of 
injuring the maternal structures, and, in the hands of a nervous or 
inexperienced operator, this danger, which is entirely avoided in ceph- 
alotripsy, is far from slight. The passage of the blades of the cephalo- 
tribe is by no means difficult, and I think it must be admitted that the 
possible risks attending it are comparatively small. On account, there- 
fore, of its simplicity and safety to the maternal structures, I believe 
cephalotripsy to be decidedly the preferable operation in all cases of 
moderate obstruction. 

AVhen we approach the lower limit, and have to do with a very 
marked amount of pelvic deformity, the two operations stand on a 
more equal footing. Then the deformity may be so great as to render 
it difficult to pass the blades of even the smallest cephalotribe sufficiently 
deep to grasp the head firmly, and even when they are passed, the space 
is often so limited as to impede the easy working of the instrument. 
Besides this, repeated crushings may be required to diminish the skull 
sufficiently. I attach but little importance to the argument that the 
diminution of the skull in one diameter increases its bulk in another. 
The necessity of removing and replacing the blades on another part of 
the skull, and of repeating this perhaps several times, in the manner 
recommended by Pajot, is a far more serious objection. To do this in 
a contracted pelvis involves, of necessity, the risk of much contusion. 
Fortunately cases of this kind are of extreme rarity, much more so 
than is generally believed, but when they do occur they tax the resources 
of the practitioner to the utmost. 

On the whole, the conclusion I would be inclined to arrive at with 
regard to the two operations is, that in all ordinary cases cephalo- 
tripsy is safer and easier, whereas in cases with considerable pelvic 
deformity, the advantages of cephalotripsy are not so well marked, 
and craniotomy may even prove to be preferable. 

The first step in using the cephalotribe is the passage of the blades. 
These are to be inserted in precisely the same manner, and with the 
same precautions, as in the high forceps operation. In many cases the 
os is not fully dilated, and it is absolutely essential to pass the instru- 
ment within it. Special care should, therefore, be taken to avoid any 
injury to its edges, and, for this purpose, two or three fingers of the left 
hand, or even the whole hand, should be passed high up, so as thoroughly 
to protect the maternal structures. In order that the base of the skull 



532 



OBSTETRIC OPERATIONS. 



Fig. 196. 



may be reached and effectually crushed, the blades must be deeply 
inserted, and, in doing this, great care and gentleness must be used. As 
the projecting promontory of the sacrum generally tilts the head for- 
ward, the handles of the instrument, after locking, must be well pressed 
backward toward the perineum. If the blades do not lock easily, or 
if any obstruction to their passage be experienced, one of them must 
be withdrawn and reintroduced, just as in a forceps operation. Care 
must be taken, as the instrument is being inserted, to fix and steady 
the head by abdominal pressure, since it is generally far above the 
brim and would readily recede if this precaution were neglected. 
"When the blades are in situ, we proceed to crush by turning the screw 
slowly, and as the blades are approximated the bones yield and the 
cephalotribe sinks into the cranium. The crushed portion then meas- 
ures, of course, no more than the thickness of the blades, that is, about 
one and one-half inches. This is necessarily accompanied by some 
bulging of the part of the cranium that is not within the grasp of the 

instrument (Fig. 196), but in slight de- 
formity this is of no consequence and we 
may proceed to extraction, waiting, if pos- 
sible, for a pain, and drawing at first down- 
ward in the axis of the pelvic inlet, as in 
forceps delivery, then in the axis of the 
outlet. The site of perforation should be 
examined to see that no spiculae of bone are 
projecting from it, and if so they should 
be carefully removed. In such cases the 
head often descends at once, and with the 
greatest ease. Should it not do so, or 
should the obstruction be considerable, a 
quarter turn should be given to the handles 
of the instrument, so as to bring the crushed 
portion into the narrower diameter and 
the uncrushed portion into the wider trans- 
verse diameter. It may now be advisable 
to remove the blades carefully, and to re- 
introduce them with the same precautions 
so as to crush the unbroken portion of the 
skull. This adds materially to the diffi- 
culties of the case, since the blades have a 
tendency to fall into the deep channel 
already made in the cranium, and so it is 
by no means always easy to seize the skull 
in a new direction. Before reapplying 
them, if the condition of the patient be 
good and pains be present, it may be well 
to wait an hour or more, in the hope of the 
head being moulded and pushed down into 
the pelvic cavity. This was the plan adopted by Dubois, and, accord- 
ing to Tarnier, was the secret of his great success in the operation. 
Pajot's method of repeated crushings, in the greater degrees of contrac- 




Fcetal head crushed by the 
cephalotribe. 



OPERATIONS INVOLVING DESTRUCTION OF FOETUS. 533 



Fig. 197. 



tion, is based on the same idea, and he recommends that the instrument 
should be introduced at intervals of two, three, or four hours, accord- 
ing to the state of the patient, until the head is thoroughly crushed ; 
no attempts at traction being used, and expulsion being left to the 
natural powers. This, he says, should always be done when the con- 
traction is below two and one-half inches, and he maintains that it is 
quite possible to effect delivery by this means when there is only one 
and one-half inches in the antero-posterior diameter. The repeated 
introduction of the blades in this fashion must necessarily be hazard- 
ous, except in the hands of a very skilful operator ; and I believe that 
if a second application fail to overcome the difficulty, which will only 
be very exceptionally the case, it would be better to resort to the meas- 
ures presently to be described. 

Prof. Alex. R. Simpson, of Edinburgh, 1 has suggested the use of an 
instrument which he calls a " basilyst." Its object is to break up the 
base of the foetal skull from within, after the method 
originally proposed by Guyon. The screw-like portion 
of the instrument (Fig. 197), which is inserted through 
the perforation made in the cranial vault, is driven 
through the hard base, which is then disintegrated by 
the separate movable blade. If experience proves that 
this instrument can be readily worked, it promises to be 
a valuable addition to our armamentarium, since it will 
effectually destroy the most resistant portion of the skull, 
without risk of injury to the maternal structures, and 
thus very materially facilitate extraction. 

Extraction by the Craniotomy Forceps. — Should 
we elect to trust to the craniotomy forceps for extraction, 
one blade is to be introduced through the perforation, and 
the other, placed in opposition to it, on the outside of the 
scalp. In moderate deformities, traction applied during 
the pains may of itself suffice to bring down the head. 
Should the obstruction be too great to admit of this, it is 
necessary to break down and remove the vault of the 
cranium. For this purpose Simpson's cranioclast answers 
better than any other instrument. One of the blades is 
passed within the cranium, the other, if possible, between the scalp 
and the skull, and the portion of bone grasped between them is broken 
off; this can generally be accomplished by a twisting motion of the 
wrist, without using much force. The separated portion of bone is 
then extracted, the greatest care being taken to guard the maternal 
structures, during its removal, by the fingers of the left hand. The 
instrument is then applied to a fresh part of the skull, and the same 
process repeated until as much of the vault of the cranium as may be 
necessary is broken up and removed. 

Dr. Braxton Hicks 2 has conclusively shown that in difficult cases, 
after the removal of the cranial vault, the proper procedure is to bring 
down the face, since the smallest measurement of the skull after the 



Prof. A. R. Simp- 
son's basilyst. 



^ Edin. Med. Journ , vol. 1879-80, p. 



2 Obst. Trans., 1867, vol. vii. p. 57. 



534 



OBSTETRIC OPERATION'S 



removal of the upper part of the cranium is from the orbital ridge to 
the alveolar edge of the superior maxillary bone. This alteration in 
the presentation he proposes to effect by a small blunt hook made 
for the purpose, which is forced into the orbit, by means of which the 
face is made to descend. Barnes recommends that this should be done 
by fixing the craniotomy forceps over the forehead and face, and 
making traction in a backward direction, so as to get the face past the 
projecting promontory of the sacrum. The importance of bringing 
down the face was long ago pointed out by Burns, but it had been lost 
sight of until Hicks again drew attention to it in the paper referred 
to. In the class of cases in which this procedure is valuable, the risk 
to the maternal passages, from the removal of the fractured portions 
of bone, must always be considerable, and it is of great importance 
not only to preserve the scalp as entire as possible, so as to protect 
them, but to use the utmost possible care in removing the broken 
pieces of bone. 

Extraction of the Body. — When the extraction of the head has 
been effected, either by the cephalotribe or the craniotomy forceps, 
there is seldom much difficulty with the body. By traction on the 
head one of the axillae can easily be brought within reach, and if the 
body does not readily pass, the blunt hook should be introduced and 
traction made until the shoulder is delivered. The same can then be 
done with the other arm. If there be still difficulty, the cephalotribe 
may be used to crush the thorax. The body is, however, so com- 
pressible that this is rarely required. 



[Fig. 198. 



LFig. 199. 




Straight craniotomy forceps.] 



Curved craniotomy forceps.] 



[The craniotomy forceps chiefly in use with us were devised by the 
late Prof. Charles D. Meigs for his second operation upon Mrs. Key- 
bold, of Philadelphia, in 1833, and have been used repeatedly since, 
either as tractors or for reducing the size of the foetal head, in cases of 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 535 

deformity of the pelvis. 1 Some obstetricians prefer the less curved 
and broader-bladed instrument of Great Britain as a tractor; but for 
the general purposes of picking away the cranial bones and drawing 
down the base of the skull in cases of extreme pelvic deformity there 
is no more simple appliance than that of Dr. Meigs. 

To act upon an oval body like the foetal head, Dr. M. was obliged to 
prepare two forms of forceps — straight and curved — to be used as 
might be required according to the part of the skull to be broken down 
or drawn upon. These are lightly made, serrated, and twelve and a 
half inches in length. — Ed.] 

Embryotomy. — There only remains for us to consider the second 
class of destructive operations. These may be necessary in long- 
neglected cases of arm presentation, in which turning is found to be 
impracticable. Here, fortunately, the question of killing the foetus 
does not arise, since it will, almost necessarily, have already perished 
from the continuous pressure. We have two operations to select from, 
decapitation and evisceration. [And a third, the improved Csesarean 
section. — Ed.] 

The former of these is an operation of great antiquity, having been 
fully described by Celsus. It consists in severing the neck, so as to 
separate the head from the body ; the body is then withdrawn by 
means of the protruded arm, leaving the head in utero to be subse- 
quently dealt with. If the neck can be reached without great difficulty 
— and, in the majority of eases, the shoulder is sufficiently pressed down 
into the pelvis to render this quite possible — there can be no doubt that 
it is much the simpler and safer operation. 

The whole question rests on the possibility of dividing the neck. 
For this purpose many instruments have been invented. The one 
generally recommended in this country is known as Ramsbotham's 
hook, and consists of a sharply curved hook with an internal cutting 
edge. This is guided over the neck, which is divided by a sawing 
motion. There is often considerable difficulty in placing the instru- 
ment over the neck, although, if this were done, it would doubtless 
answer well. Others have invented instruments, based on the principle 
of the apparatus for plugging the nostrils, by means of which a spring 
is passed round the neck, and to the extremity of the spring a short 
cord, or the chain of an ecraseur, is attached ; the spring is then with- 
drawn and brings the chain or cord into position. The objection to 
any of these apparatus is, that they are unlikely to be at hand when 
required, for few practitioners provide themselves with costly instru- 
ments which they may never require. It is of importance, therefore, 
that we should have at our command some means of dividing the neck 
which are available in the absence of any of these contrivances. 
Dubois recommended for this purpose a strong pair of blunt scissors. 
The neck is brought as low as possible by traction on the prolapsed 
arm, and the blades of the scissors guided carefully up to it. By a 
series of cautious snipping movements it is then completely divided 
from below upward. This, if the neck be readily within reach, can 

[' The illustrations given are taken from the instruments devised by Dr. Meigs as an improve- 
ment upon his original pattern, and will be seen to differ from those usually presented in American 
obstetrical publications.— Ed.] 



536 OBSTETRIC OPERATIONS. 

generally be effected without any particular difficulty. Dr. Kidd, of 
Dublin/ who strongly advocated this operation, recommended that an 
ordinary male elastic catheter, strongly curved and mounted on a firm 
stilet, or, still better, on a uterine sound, should be passed round the 
neck. Previous to introduction a cord should be passed through the 
eye of the catheter, which is left round the neck when it is withdrawn. 
By means of this cord a strong piece of whipcord, or the wire of an 
ecraseur, can easily be drawn round the neck and used for dividing it. 
The former, to protect the maternal structures, may be worked through 
a speculum, and by a series of lateral movements the neck is easily 
severed. The Ecraseur, however, offers special advantage, since it 
entirely does away with any risk of injuring the mother. 

Withdrawal of the Body and Delivery of the Head. — After the 
neck is divided the remainder of the operation is easy. The body is 
withdrawn without difficulty by the arm, and we then proceed to 
deliver the head. By abdominal pressure, this, in most cases, can be 
pushed down into the pelvis, so as to come easily within reach of the 
cephalotribe, which is by far the best instrument for extraction. Pre- 
liminary perforation is not necessary, since the brain can escape through 
the severed vertebral canal. The secret of doing this easily is to fix 
and press down the head sufficiently from above, otherwise it would 
slip away from the grasp of the instrument. The perforator and 
craniotomy forceps may be used, if the cephalotribe be not at hand. 
Perforation is, however, by no means always easy, on account of the 
mobility of the head. After it is accomplished, one blade of the 
craniotomy forceps is passed within the skull, the other externally, and 
the head slowly drawn down. 

Evisceration. — The alternative operation of evisceration is a much 
more troublesome and tedious procedure, and should only be used when 
the neck is inaccessible. The first step is to perforate the thorax at its 
most depending part, and to make as wide an opening into it as pos- 
sible, in order to gain access to its contents. Through this the thoracic 
viscera are removed piecemeal, being first broken up as much as possible 
by the perforator, and then, the diaphragm being penetrated, those in 
the abdomen. The object is to allow the body to collapse and the 
pelvic extremities to descend, as in spontaneous evolution. This can 
be much facilitated by dividing the spinal column with a strong pair 
of scissors introduced into the opening made in the thorax, so that the 
body may be doubled up as on a hinge. Here the crotchet may find a 
useful application, for it can be passed through the abdominal cavity 
and fixed on some point in the interior of the child's pelvis, and thus 
strong traction can be made without any risk of injury to the mother. 
It can be readily understood that this process is so lengthy and difficult 
as to render it probably the most trying of obstetric operations ; it is 
certainly inferior in every respect to decapitation, and is only to be 
resorted to when that is impracticable. 2 

1 Dublin Quart. Journ. of Med. Science. 1871, vol. li. p. 3S3. 

2 In nine cases of impaction of the foetus in a transverse position, in the United States, the 
Cesarean operation has been performed, owing to great difficulty in accomplishing either decapi- 
tation or evisceration, and six of the women were saved. The three deaths were from exhaustion. 
—Harris's note to third American edition. 



CESAREAN" SECTION. 637 



CHAPTEE VI. 

THE CESAREAN SECTION— PORRO-CiES ARE AN OPERATION. 

History of the Caesarean Section. — The Cesarean section lias 
perhaps given rise to more discussion than any other subject connected 
with midwifery, and there is yet much difference of opinion as to the 
limits of, and indications for, the operation. The period at which the 
Cesarean section was first resorted to is not known with accuracy. It 
seems to have been practised by the Greeks, after the death of the 
mother ; and Pliny mentions that Scipio Africanus and Manlius were 
born in this way. The name of Caesar is said to have been given to 
children so extracted, and afterward to have been assumed as a family 
patronymic. These children were dedicated to Apollo, whence arose 
the practice of things sacred to that god being taken under the special 
protection of the family of the Caesars. Many celebrities have been 
supposed to owe their lives to the operation, among the rest JEscula- 
pius, Julius Caesar, and Edward VI. of England. Regarding the two 
latter, there is conclusive proof that the tradition is without foundation. 
There is no doubt that the operation was constantly practised on 
women who had died at an advanced period of pregnancy, and indeed 
it has, at various times, been enforced by law. Thus, among the 
Romans it was decreed by jNuina that no pregnant woman should be 
buried until the foetus had been removed by abdominal section. The 
Italian laws also made it necessary, and the operation has always 
received the strong support of the Roman Church. So lately as the 
middle of the eighteenth century, the King of Sicily sentenced to death 
a physician who had neglected to practise it. The first authentic case 
in which the operation was performed on a living woman occurred in 
1491. It was afterward practised by Nufer in 1500J] 1 ] ; and in 1581 
Rousset published a work on the subject in which a number of suc- 
cessful cases were related. In English works of that time it is not 
alluded to, although it was undoubtedly performed on the Continent, 
and to such an extent that its abuse became almost proverbial. We 
have evidence in Shakespeare, however, that the operation was famil- 
iarly known in Great Britain, since he tells us that — 

. . . Macduff was from his mother's womb 
Untimely ripped. 

[This is much more likely to refer to a horn-rip, as the original 
expression, " ripped out," would indicate. Fourteen such operations 
under the horn-thrusts of the bull, ox, cow, bison, and buffalo have been 
recorded, and ten women with seven children escaped death. Mrs. 

[i 1498.— Ed.] 



538 OBSTETRIC OPERATIONS. 

Macduff was probably operated upon by a cow. — Ed.] Pare and 
Guillemeau, amongst the writers of the period, were noted for their 
hostility to the operation, while others equally strongly upheld it. 

In England it has, until recently, scarcely ever been performed in a 
manner which offers even the faintest hope of success. It has been 
looked upon as almost necessarily fatal to the mother, and it has, 
therefore, been delayed until the patient has arrived at the utmost 
stage of exhaustion. For example, in looking over the records of 
British cases, it is no uncommon thing to find that the Cesarean sec- 
tion was resorted to, two, three, or even six days after labor had begun, 
and when the patient was almost moribund. AVith rare exceptions 
[up to] within the last few years, the operation has been performed 
[in England] in what may be called a hap-hazard way. In many 
cases long and fruitless attempts at delivery by craniotomy had 
already been made, so that the passages had been subjected to much 
contusion and violence. Little or no attempt has been made to obviate 
the well-known risks of abdominal operations ; no care has been taken 
to prevent blood and other fluids finding their way into the peritoneal 
cavity, and no means have been adopted subsequently to remove them. 
It is, therefore, not so much a matter of surprise that the mortality 
has been so great, but rather that any cases have recovered. 

From what we know of the history of ovariotomy, its early fatality, 
and the extreme and even apparently exaggerated precautions which 
are essential to its success, it is fair to conclude that, if the Cesarean 
section were performed, as it is to be hoped it always will be in future, 
with the same careful attention to minute details as ovariotomy, the 
results would not be so disastrous. Making every allowance for these 
facts, it must he admitted that the Cesarean section, as hitherto per- 
formed, has been necessarily almost a forlorn hope ; although happily 
recent statistics show that this need no longer be considered the case. 
In making these observations I have no intention of contesting the 
well-established rule of British practice that it is not admissible as an 
operation of election, and must only be resorted to when delivery per 
vias naturales is impossible. 

Statistical Returns are not Reliable. — The mortality, as given in 
statistical returns from various sources, differs so greatly as to make 
them but little reliable. Radford has tabulated the operations per- 
formed in England up to 1879, and the list has been completed by 
Harris up to 1889. The cases amount to 154 in all, of which 32 were 
successful. Michaelis and Kayser [1833 and 1841] found that out of 
'2oS cases and 338 operations, 54 and 64 per cent, respectively were fatal. 
These include operations performed under all sorts of conditions, even 
when the patient was almost moribund ; and until we are in possession 
of a sufficient number of cases performed under conditions showing 
that the result is certainly due to the operation — in Avhich it was under- 
taken at an early period of labor and performed with a reasonable 
amount of care — it is obviously impossible to arrive at any reliable 
conclusions as to the mortality of the operation. That it is necessarily 
hopeless is certainly not the case, and we know that on the Continent, 
where it is resorted to much oftener and earlier in labor than in Eng- 



CESAREAN SECTION. 539 

laud, there are authentic cases in which it has been performed twice, 
thrice, and even, in oue instance, lour times on the same patient. 
Kavser [1841] thought that a second operation on the same patient 
afforded a better prognosis than a first, probably because peritoneal 
adhesions, resulting from the first operation, have shut off the general 
abdominal cavity from the uterine wound ; and he believed that in 
second operations the mortality is not more than 29 per cent. 

The Csesarean Section in America. — The Cesarean section [thus 
far] has been more successful in America than in Great Britain. Dr. 
Harris, of Philadelphia, who has paid much attention to the subject, 
has collected 23-4 cases occurring in the United States, of which 105, 
or over 44 per cent., were successful as regards the mother, f 1 ] These 
favorable results he refers partly to the fact that none of the American 
cases were the subjects of mollities ossiuin, rhachitic patients forming 
one-half of the entire number. He also gives some interesting facts 
showing how remarkably the mortality of the operation Avas lessened 
under the old method, Avhen performed soon, and the patient was not 
exhausted by long and fruitless labor. Out of 28 selected cases of this 
kind, 21, or 75 per cent., were successful. The latest European statis- 
tics show that the modifications of the operation now universally 
adopted upon the Continent of Europe are followed by the most grati- 
fying results. [Of 54 women operated upon in Leipzig, 51 recovered ; 
34 were saved out of 38 in Dresden ; 16 were delivered under the 
section in the Krankenhaus of Yienua, in order, without a death, and 
Dr. Murdoch Cameron, of Glasgow, has only lost 3 out of 30. Here 
we have a record of 138 cases with 128 recoveries, a mortality of 7^ 
per cent., showing the possibilities of this method of delivery in well- 
appointed maternities, and under competent operators. In view of 
these facts, we are inclined in our country to estimate the danger of 
the operation according thereto. — Ed.] 

Results to the Child. — The mortality of the children likewise can- 
not be ascertained from statistical returns, since, in the large majority 
of cases in which dead children were extracted, the result had nothing 
to do with the operation. Indeed, there is nothing in the operation 
itself which can reasonably be supposed to affect the child. If, there- 
fore, the child be alive when the operation is commenced, there is 
every probability of its being extracted alive ; and Radford's conclu- 
sion, that " the risks to infants in Csesarean births is not much greater 
than that which is contingent on natural labor, provided correct prin- 
ciples of practice are adopted/' probably very nearly represents the 
truth. 

Causes Requiring" the Operation. — The Csesarean section is re- 
ouired when there is such defective proportion between the child and 
the maternal passages that even a mutilated foetus cannot be extracted. 
This in by far the greatest number of cases is due to deformity of the 
pelvis arising from rickets or mollities ossium. The latter may occur 
in a patient who has been previously healthy, and who lias given birth 
to living children. It is a more common cause of the extreme varieties 

[ l By the old method, 1-16, with 90 deaths -and by the new, 79, with 29 deaths. 2 died out of 
the last 20.— Ed.] 



540 OBSTETRIC OPERATIONS. 

of deformity than rickets ; and out of 132 British cases tabulated by 
Radford, in 56 the deformity was produced by osteomalacia, and in 31 
by rickets. [ x ] In certain cases the pelvis itself may be of normal size, 
but has its cavity obstructed by a solid tumor of the ovary, of the 
uterus itself, or one growing from the pelvic wall. The obstruction 
may also depend on morbid conditions of the maternal soft parts, of 
which the most common is advanced malignant disease of the cervix. 
Other conditions may, however, render the operation essential. Thus 
Dr. Newman 2 recorded a case in which he performed it for insurmount- 
able resistance and obstruction of the cervix, Avhich was believed at the 
time to be caused by maliguant disease. The patient recovered, and 
was subsequently delivered naturally, and without anything abnormal 
being made out. This renders it probable that the disease was not 
malignant, and it may possibly have been an extensive inflammatory 
exudation into the tissues of the cervix, subsequently absorbed. I 
myself was present at a Csesarean section performed in Calcutta in the 
year 1857, when the pelvis was so uniformly blocked up with exuda- 
tion, probably due to extensive pelvic cellulitis or haematocele, that the 
operation was essential. 

Limits of Obstruction Justifying" the Operation. — Different 
accoucheurs have fixed on various limits for the operation. Most 
British authorities are of opiuion that it need not be resorted to if the 
smallest diameter of the pelvis exceed one and a half inches. 3 This 
question has already been considered in discussing craniotomy, and it 
has been shown that a mutilated foetus may be drawn through a pelvis 
of one and a half inches antero-posterior diameter, provided there be a 
space of three inches in the transverse diameter. If sufficient space for 
using the necessary instruments does not exist, the Csesarean section 
may be required, even when there is a larger antero-posterior diameter 
than one and a half inches. This is especially likely to occur when 
we have to do with deformity arising from mollifies ossium, in which 
the obstruction is in the sides and outlet of the pelvis, the true con- 
j ugate being sometimes even elongated. On the Continent the Csesarean 
section is constantly practised as an operation of election when the 
smallest diameter measures from two to two and a half inches ; and 
when the child is known to he alive, some foreign authors recommend 
it when there is as much as three inches in the antero-posterior diameter. 
In Great Britain, where the life of the child is most properly con- 
sidered of secondary importance to the safety of the mother, we cannot 
fix one limit for the operation when the child is living, and another 
when it is dead. Nor, I think, can we admit the desire of the mother 
to run the risk, rather than sacrifice the child, as a justification of the 
operation, although this is laid down as an indication by Schroeder. 4 
Great as are the dangers attending craniotomy in extreme deformity, 
there can be no doubt that we must perform it whenever it is prac- 

f 1 Observations on the Csesarean Section, etc., 2d edition, 1880.— Ed.] 

2 Obst. Trans., 1866, vol. vii. p. 343. 

3 In Dr. Parry's table of 70 craniotomies, there are 34 cases of two to two and a half inches con- 
jugate. [British authorities are changing their views very materially in regard to the applicability 
■of the Csesarean section to cases formerly delivered by craniotomy. — Ed.] 

4 Manual of Midwifery, p. 202. 



CESAREAN SECTION. 541 

ticable, and only resort to the Cesarean section when no other means 
of delivery are possible. [*] 

For this reason I think it unnecessary to discuss the question 
whether we are justified in destroying the foetus in several successive 
pregnancies, when the mother knows that it is impossible for her to 
give birth to a living child. Denman was the first to question the 
advisability of repeating craniotomy on the same patient. Amongst 
modern authors Baclford took the most decided view on this point, 
and distinctly taught that even when delivery by craniotomy is 
possible, it " can be justified on no principle, and is only sanctioned 
by the dogma of the schools, or by usage," and that, therefore, the 
Cesarean section should be performed with the view of saving the 
child. Doubtless much can be said from this point of view; but, 
nevertheless, he would be a bold man who would deliberately elect 
to perform the Cesarean section on such grounds. 2 It is to be 
hoped, however, that in these days the induction of premature labor 
or abortion would always spare us the necessity of deciding so delicate 
a point. 

[One of the vital questions of the day is, " Shall the Csesarean opera- 
tion be performed in cases under relative indications?" That is, Is it 
proper to elect to perform the operation where the indications for it 
are not absolute and positive? If by foetal destruction the mother can 
in all probability be saved, is it a justifiable act to run a greater risk 
in order to save the child? Are the wishes of the parents for a living 
child to be considered in deciding as to the method of delivery ? In 
view of the fact that a premature delivery cannot save the child in a 
given case, and the mother has already lost one or more foetuses by 
craniotomy, is it proper to save the child by an operation in which 
from 6 to 10 per cent, of women die? We think it is, and should be 
performed. — Ed.] 

Post-mortem Csesarean Operation. — The Csesarean section may 
also be required in cases in which death has occurred during pregnancy 
or labor. This was the indication for which it was first employed, and 
it has constantly been performed when a pregnant woman has died at 
an advanced period of utero-gestation. There is no doubt that a 
prompt extraction of the child under these circumstances has fre- 
quently been the means of saving its life, but by no means so often as 
is generally supposed. Thus, Schwarz 3 showed that out of 107 cases 
not one living child was extracted. Duer* has written an interesting 
paper on this subject, in which he has tabulated 55 cases of post-mortem 
Csesarean sections. In 40 a living child was extracted, the time elapsing 
after the death of the mother being as follows • " Between one and five 
minutes, including ' immediately ' and ' in a few minutes/ there were 
21 cases ; between five and ten minutes, none ; between ten and fifteen 
minutes, 13 cases; between fifteen and twenty-three minutes, 2 cases; 

[* This opinion is not held in our country.— Ed 1 

2 This was done twice successfully by Prof. William Gibson in the case of Mrs. Reybold, of 
Philadelphia, in 1835 and 1837, after she had twice been delivered by craniotomy under Prof. Charles 
D. Meigs, who declined destroying any more children for her.— Harris's note to third American 
edition. 

3 Monats. f. Geburt., suppl., 1862, Bd. xviii. S. 112 

4 "Post-mortem Delivery," Amer. Journ. of Obst,, 1879, vol. xii. pp. 1 and 374. 



542 OBSTETEIC OPERATIONS. 

after one hour, 2 cases; and after two hours, 2 cases." In those ex- 
tracted, however, after the lapse of an hour, the children did not ulti- 
mately survive, and the cases themselves seem open to some doubt. 

"Want of Success in Post-mortem Operation. — The reason that 
the want of success has been so great is doubtless the delay that must 
necessarily occur before the operation is resorted to ; for, independently 
of the fact that the practitioner is seldom at hand at the moment of 
death, the very time necessary to assure ourselves that life is actually 
extinct will generally be sufficient to cause the death of the fcetus. 
Considering the intimate relations between the mother and child, we 
can scarcely expect vitality to remain in the latter more than a quarter 
or, at the outside, half an hour after it has ceased in the former. The 
recorded instances in which a living child was extracted ten, twelve, 
and even forty hours after death, were most probably cases in which 
the mother fell into a prolonged trance or swoon, during the con- 
tinuance of which the child must have been removed. A few authentic 
cases, however, are known in which there can be no reasonable doubt 
that the operation was performed successfully several hours after the 
mother w r as actually dead. 

Since, then, there is a chance, however slight, of saving the child's 
life, we are bound to perform the operation, even when so much time 
has elapsed as to render the chances of success extremely small. It 
might be considered almost superfluous to insist on the necessity of 
assuring ourselves of the mother's death before commencing the neces- 
sary incisions ; but, unfortunately, numerous instances are known in 
which mistakes in diagnosis have been made, and in which the first 
steps of the operation have shown that the mother was still alive. The 
operation should, therefore, always be performed with the same care 
and caution as if the mother were living. If death has occurred 
during labor, some have advised version as a preferable alternative. 
This can only be resorted to, with any hope of success, if the passages 
be in a condition to admit of delivery with rapidity ; otherwise the 
delay occasioned by dilatation, even when forcibly accomplished, and 
the drawing of the child through the pelvis, will be almost necessarily 
fatal. The only argument in favor of version is that it is less painful 
to the friends ; and if they manifest a decided objection to the Cesarean 
section, there can be no reason why an attempt to save the child in 
this way should not be made. 

Causes of Death after Csesarean Section. — The causes of death 
after the Caesarean section may, speaking generally, be classed under 
four principal heads : hemorrhage, peritonitis and metritis, shock, sep- 
ticaemia and exhaustion from long delay. These are pretty much the 
same as those following ovariotomy, and the resemblance between the 
two operations is so great that modern experience as to the best mode 
of performing ovariotomy, as well as regards the after-treatment, 
may be taken as a guide in the management of cases of Cesarean 
section. 

Hemorrhage to an alarming extent is a frequent complication, 
though seldom the cause of death. Thus, out of eighty-eight opera- 
tions, the particulars of which have been carefully noted, severe 



< KSAREAX SECTION. 543 

hemorrhage occurred in fourteen, six of which terminated successfully, 

and in four only could the fatal result be ascribed to the loss of blood. 
In one of these the source of tin 1 hemorrhage is not mentioned, in 
another it came from the wound in the abdominal vail, and in the 
other two from the uterine incision being made directly over the pla- 
centa. In neither of the two latter was the loss of blood immediately 
fatal; for it was checked by uterine contraction, and only recurred 
after many hours had elapsed. The divided uterine sinuses, and the 
open mouths of the vessels at the placental site, are the most common 
sources of hemorrhage. 

Much may be done to diminish the risk of bleeding, but even with 
every precaution it must be a source of danger. Hemorrhage from 
the abdominal wall may be best prevented by making the incision as 
nearly as possible in the line of the linea alba, so as not to wound the 
epigastric arteries, and by controlling bleeding by pressure forceps as 
we proceed, as is done in ovariotomy. The principal loss of blood 
will be met with in dividing the uterus ; and this will be the greatest 
when the incision is near or over the placental site, where the largest 
vessels are met with. AVe are recommended to ascertain the position 
of the placenta by auscultation, and thus, if possible, to avoid opening 
the uterus near its insertion. But even if we admit the placental 
souffle to be a guide to its situation, if the placenta be attached to the 
anterior walls of the uterus, a knowledge of its position would not 
always enable us to avoid opening the uterus in its immediate vicinity. 
We must, in the event of its lying under the incision, rather hope to 
control the hemorrhage by removing it at once from its attachments, 
and rapidly emptying the uterus. When the child has been removed 
there may be a large escape of blood ; but this will generally be stopped 
by the contraction of the uterus, in the same manner as after natural 
labor. Should contraction not take place, the uterus may be firmly 
grasped for the purpose of exciting it. This plan was advocated by 
the late Ludwig TT inckel, who had a large experience in the operation ; 
and by using free compression in this way, and making a point of not 
closing the wound until the uterus was firmly contracted, he had never 
met with any inconvenience from hemorrhage. Sanger, to whose 
writings we owe so much in perfecting the modern Cesarean section, 
relies much on frequent kneading of the uterus during the application 
of the sutures. Murdoch Cameron, of Glasgow, 1 who has had the 
largest experience of the operation amongst British operators, recom- 
mends that the cut surfaces of the uterus should be firmly pressed 
together. [ 2 ] He also places a hard-rubber oval pessary on the uterus 
before commencing the incision, which is made within the oval, and 
by this means, he says, the chance of hemorrhage is lessened. If 
bleeding continue, styptic applications may be used, as in a case 
reported by Hicks, who was obliged to swab out the uterine cavity 
with a solution of perchloride of iron. The method first used by Litz- 
mann, and adopted since by many operators, of placing a soft-rubber 
cord around the cervix, after the uterine contents have been removed, 

1 British Med. Journ., March 7, 1£ 

[ 2 Up to July 7, 1893, he operated on 30 women , and saved 27 of them.— Ed.] 



544 OBSTETRIC OPERATIONS. 

will tend effectually to control hemorrhage, but Cameron objects to it 
as likely to induce inertia after its removal. f 1 ] 

Among the most frequent causes of death are peritonitis and metritis. 
Kayser attributed the fatal results to them in 77 out of 123 unsuccess- 
ful cases. 

The mere division of the peritoneum will not account for the fre- 
quency of this complication, since its occurrence is considerably more 
frequent than after ovariotomy, in which the injury to the peritoneum 
is quite as great — and indeed greater, if we take into account the 
adhesions which have to be divided or torn in that operation. 

The division of the uterus must be regarded as one source of this 
danger. Dr. West lays great stress on its unfavorable condition after 
delivery for reparative action. He believes that the process of invo- 
lution or fatty degeneration which commences in the muscular fibres 
previous to delivery,' renders them peculiarly unfitted to cicatrize ; and 
he points out that, on post-mortem examination, the edges of the 
incision have been found dry, of unhealthy color, gaping, and showing 
no tendency to heal. On this account Hicks and others have operated 
ten days or more before the full period of labor, in the hope that the 
risk from this source might be avoided. It is by no means certain, 
however, that the change in the uterine fibres is the cause of the wound 
not healing, and involution will commence at once when the uterus is 
emptied, even if the full period of pregnancy have not arrived. As a 
point of ethics, moreover, it is questionable if we are justified in antici- 
pating the date of so dangerous an operation, even by a few weeks, 
unless the benefit to be derived is very decided indeed. 

One important cause of peritonitis is the escape of the lochia through 
the uterine incision into the cavity of the peritoneum, which there 
decompose and act as an unfailing source of irritation. This may be 
prevented, to a great extent, by seeing that the os uteri is patulous, so 
as to afford a channel for the escape of discharges, and by effective 
closing of the uterine wound by sutures. In addition, there is the 
danger arising from blood and liquor amnii escaping into the peri- 
toneum, and subsequently decomposing. There is little evidence that 
" la toilette du peritoine," on which ovariotomists now lay so much 
stress, has ever been particularly attended to in Cesarean opera- 
tions^ 2 ] 

The chief predisposing cause of these iuflammations, however, must 
be looked for in the condition of the patient, just as asthenic inflam- 
mation in ovariotomy is most frequently met with in those whose 
general health is broken down by the long continuance of the disease. 
We are fully justified, therefore, in assuming that peritonitis and 
metritis will be more likely to occur after the Cesarean section when 
that operation has been unnecessarily delayed, and when the patient 
is exhausted by a protracted labor. In proof of this we find that, in 
a large proportion of the cases above mentioned, peritonitis occurred 
when the operation was performed under unfavorable conditions. 

[! This has so often led to secondary hemorrhage after its removal, that the practice has been 
generally condemned ; manual compression is much safer.— Ed.] 
[ 2 See German and Austrian reports of operations performed within the last ten years— Ed. J 



CESAREAN SECTION. 545 

The sources of septicaemia are abundantly evident; not the least, 
probably, being absorption by the open vessels in the uterine incision. 

The last great danger is general shock to the nervous system. In 
Kayser's 12:> cases, SO of the deaths are referred to this cause. In 
the large majority of these the patient was profoundly exhausted 
before the operation was begun. It is in predisposing to these nervous 
complications that Ave should, a priori, expect that vacillation and 
delay would be most hurtful ; and in operating when the patient's 
strength is still unimpaired, we afford her the best chance of bearing 
the inevitable shock of an operation of such magnitude. 

In addition, a few cases have been lost from accidental complications, 
which are liable to occur after any serious operation, and which do not 
necessarily depend on the nature of the procedure. 

There is only one source of danger special to the child which is 
worthy of attention. As the infant is being removed from the cavity 
of the uterus, the muscular parietes sometimes contract with great 
rapidity and force, so as to seize and retain some part of its body. 
This occurred in two of Dr. Radford's cases, and in one of them it is 
stated that " the child was vigorously alive when first taken hold of, 
but, from the length of time occupied in extracting the head, it became 
so enfeebled as to show only slight signs of life," and subsequently all 
attempts at resuscitation failed. I have myself seen the head caught 
in this way, and so forcibly retained that a second incision was re- 
quired to release it. In Dr. Radford's cases the placenta happened to 
be immediately under the incision, and he attributes the inordinate 
and rapid contraction of the uterus to its premature separation. It is 
difficult to believe that this was more than a coincidence, because the 
contraction does not take place until the greater part of the child's 
body has been withdrawn, and because numerous cases are recorded in 
which the uterus was opened directly over the placenta, or in which 
it was lying loose and detached, in none of which this accident occurred. 
The true explanation may, I think, be found in the varying irritability 
of the uterus in different cases. 

Irrespective of the risk of portions of the child being caught and 
detained, rapid contraction is a distinct advantage, since the danger of 
hemorrhage is thereby thus diminished. Serious consequences may be 
best avoided by removing, when practicable, the head and shoulders 
of the child first, or by employing both hands in extraction, one being 
placed near the head, the other seizing the feet. Either of these 
methods is preferable to the common practice of laying hold of the 
part that may chance to lie most conveniently near the line of incision. 
If this point were properly attended to, although the detention of the 
lower extremities might occasionally occur, the life of the child would 
not be imperilled. [*] 

The Patient should be Prepared for the Operation. — The 
preparation of the patient for the operation should seriously occupy 
the attention of the practitioner, and this is the more essential since 
almost all patients requiring the Cesarean section are in a wretchedly 

[)- Under the old operation the foetus was, as a rule, extracted by the feet. Cameron and some 
others now recommend to deliver by the head. — Ed.] 

'6b 



546 OBSTETRIC OPERATIONS. 

debilitated condition. If the patient be not seen until she is actually 
in labor, of course this is out of the question. But this will rarely be 
the case, since the deformed condition of the patient must generally 
have attracted attention. Every possible means should be taken, 
therefore, when practicable, to improve the general health by abun- 
dance of simple and nourishing diet, plenty of fresh air, and suitable 
tonics (amongst which preparations of iron should occupy a prominent 
place), while the state of the secretions, the bowels, skin, and kidneys, 
should be specially attended to. Whenever it is possible a large, airy 
apartment should be selected for the operation, which should never be 
done in a hospital, if other arrangements be practicable^ 1 ] These 
details may seem trivial and unnecessary ; but to insure success in so 
hazardous an undertaking no care can be considered superfluous, and 
probably the want of attention to such points has had much to do with 
increasing the mortality. 

The question arises whether we should operate before labor has com- 
menced. By selecting our own time, as some have advised, we certainly 
have the advantage of operating under the most favorable conditions, 
instead of possibly hurriedly. There are, however, numerous advan- 
tages in waiting until spontaneous uterine action has commenced, which 
seem to me to more than counterbalance the advantages of choosing 
our own time. Prominent among these is the partial opening of the 
os uteri, so as to afford a channel for the escape of the lochia, and the 
certainty of active contraction of the uterus, to arrest hemorrhage. 
Barnes recommends that premature labor should be first induced, and 
then the operation performed. This seems to me to introduce a need- 
less element of complexity ; and besides, in cases of great deformity it 
is by no means always easy to reach the cervix with the view of bring- 
ing on labor. All needful arrangements should be made, so as to avoid 
hurry and excitement when the operation is commenced, and we may 
then wait patiently until labor has fairly set in. 

The Administration of Ansesthetics. — The operation itself is 
simple. The patient should be placed on a table, in a good light, and 
with the temperature of the room raised to about 65°. Chloroform has 
so frequently been followed by severe vomiting, that it is probably 
better not to administer it. For the same reason Sir Spencer Wells 
has long given up using it in ovariotomy, and finds that chloro-methyl 
answers admirably ; ether also is devoid of the disadvantages of chloro- 
form. In one or two cases local anaesthesia has been used by means of 
two spray-producers acting simultaneously ; and this plan, if the 
patient have sufficient fortitude to dispense with general anaesthesia, has 
the further advantage of stimulating the uterus to powerful contraction. 

To insure as great a measure of success as possible, the operation 
should be performed with all the minute precautions used in ovari- 
otomy. 

Description of the Operation. — The incision should be made as much 
as possible in the line of the linea alba. On account of the deformity, 
the configuration of the abdomen is often much altered, and some have 

T 1 Modern operators prefer hospital advantages, and the revolution in saving life has "been mainlv 
effected in well-ordered maternities. — Ed.] 



CESAREAN" SECTION. 547 

advised that the incision should be made oblique or transverse, and on 
the most prominent part of the abdomen, f 1 ] The risk of hemor- 
rhage being thus much increased, the practice is not to be recommended. 
The incision, commencing a little above the umbilicus, is carried down 
for about three inches below it. The skin and muscular fibres are 
carefully divided, layer by layer, until the shining surface of the peri- 
toneum is reached, and any bleeding vessels should be secured with 
pressure forceps as we proceed. A small opening is now made in the 
peritoneum, which should be laid open along the whole length of the 
incision, upon two fingers of the left hand introduced as a guide. A 
few silk sutures, three or four, should now be passed through the upper 
end of the incision. The object of these is to temporarily close the 
abdominal parietes after the uterus is opened, so as to prevent the 
escape of the intestines, or the entrance of blood, etc., into the perito- 
neal cavity. Before incising the uterus an assistant should carefully 
support it in a proper position, and push it forward by the hands 
placed on either side of the incision, so as to bring its surface into appo- 
sition with the external wound, and prevent the escape of the intes- 
tines, and a large flat sponge should be placed on either side, between 
the uterus and the abdominal parietes, to prevent blood and liquor 
amnii entering the abdomen. If we have reason to believe that the 
placenta is situated anteriorly, we may incise the uterus on one or 
other side ; otherwise the line of incision should be as nearly as possible 
central. The substance of the uterus is next divided until the mem- 
branes are reached ; these are punctured and divided in the same way 
as the peritoneum. It is important not to puncture these until the 
uterine incision is completed, and we are ready to remove the child. 
The uterine incision should be of the same length as that in the abdo- 
men, and it should not be made too near the fundus ; for not only is 
that part more vascular than the body of the uterus, but wounds in 
that situation are more apt to gape, and do not cicatrize so favorably. 
After the uterus is opened, Dr. Ludwig AVinckel has recommended 
that the fingers of an assistant should be placed in the two terminal 
angles of the wound, so that the ends of the incision may be hooked 
up and brought into close apposition with the abdominal opening. 
By this means he prevented not only the escape of blood and liquor 
amnii into the cavitv of the peritoneum, but also the protrusion of the 
abdominal viscera. 

Removal of the Child. — AVe now divide the membranes and care- 
fully remove the child, the head and shoulders being taken out (if 
possible) first ; the placenta and membranes are afterward extracted. 
Should the placenta be unfortunately found immediately under the 
incision, a considerable loss of blood is likely to take place, which can 
only be checked by removing it from its attachments and concluding 
the operation as rapidly as possible. 

Eventration of the Uterus. — As soon as the child is removed, the 
uterus should be turned out of the abdominal cavity, which is tem- 
porarily closed by the sutures already introduced, and further protected 
by placing a large flat sjwnge behind the uterus. At the same time, 

P This was a very old recommendation ; no one prefers it now. — Ed.] 



5±8 OBSTETRIC OPERATIONS. 

hemorrhage is controlled by a rubber cord tied round the cervix. [*] 
This gives time thoroughly to attend to the suturing of the uterine 
incision, a point of great importance. The uterus should now be sur- 
rounded by soft napkins wrung out of warm 1 : 2000 perchloride of 
mercury solution. After the placenta has been removed and the hem- 
orrhage arrested we should see that the os uteri is open, so that any 
fluid in the uterine cavity may drain into the vagina. The cavity 
should also be dusted with iodoform. [ 2 ] 

Importance of Securing* Uterine Contraction. — As soon as the 
child and the secundines have been extracted, the sooner the uterus 
contracts the better. It will usually do so of itself, but should it 
remain lax and flabby, it should be pressed aud stimulated by the hand. 
"We are specially warned against handling the uterus by Ramsbotham 
and others ; but there seems no valid reason why we should not restrain 
hemorrhage in this way, as after a natural labor. The intervention of 
the abdominal parietes, in their lax condition after delivery, can make 
very little difference between the two cases. Ergotine administered 
hypodermically will also be useful in promoting efficient contraction. 

Ligature of the Fallopian Tubes. — In some recent cases the Fallo- 
pian tubes have been ligatured aud divided at the time of the operation, 
with the view of preventing future impregnation. This does not sen- 
siblv increase its risk, aud seems to be a judicious precaution in any 
case in which the pelvis is much deformed. 

Closure of the Uterine Wound. — Much of the recent success in 
this operation is due to the careful closing of the uterine incision by 
sutures. Sanger, who has paid great attention to this point, used for- 
merly to strip off the peritoneum for about five millimetres on each 
side of the incision, and then resect the muscular wall for about two 
millimetres ; this, however, he has now given up. He inserts eight to 
ten deep sutures of silk through the peritoneum and muscle, but not 
through the mucosa, taking care to turn in the peritoneal edges so as 
to bring them into accurate contact, with the view of securing rapid 
adhesion. The reason for not passing the sutures into the uterine 
cavity is to prevent the possibility of septic material finding its way 
along the track of the sutures into the peritoneum. Finally he passes 
twenty to twenty-five fine silk sutures through the inverted edges of 
the peritoneum. Cameron uses only seven to twelve deep stitches of 
silk, and reserves superficial sutures, for which he uses gut, for any 
points where it might be thought advisable to insert them. 

A point of great importance, and not sufficiently insisted on, is the 
advisability of not closing the abdominal wound until we are thor- 
oughly satisfied that hemorrhage is completely stopped, since any 
escape of blood into the peritoneum would very materially lessen the 
chances of recovery. In a successful case reported by Dr. Xewnian. 3 
the wound was not closed for nearly an hour.[ 4 ] Before doing so, all 

r 1 Recent experience prefers manual compression, as much safer. — Ed.] 

p This treatment has been largely done away with. If the child is living, no internal applica- 
tion to the uterus is thought advisable by Cameron and other operators.— Ed.] 

3 Obst. Trans.. 1867, vol. viii. p. 343. 

[* Under the new operation, the arrest of hemorrhage is usually effected by the suturing of the 
uterine wound. Twenty-five years ago the uterus was very rarely sewed up ; hence the precaution 
of Xewman. — Ed.] 



CESAREAN SECTION. 549 

blood and discharges should be carefully removed from the peritonea] 

cavity by clean soft sponges dipped in warm water. The abdominal 
wound should be closed from above downward by silk sutures, which 
should be inserted at a distance of an inch from each other and passed 
entirely through the abdominal walls and the peritoneum, at some 
little distance from the edges of the incision, so as to bring the two 
surfaces of the peritoneum into contact. By this means we insure the 
closure of the peritoneal cavity, the opposed surfaces adhering with 
great rapidity. If, as should be the case, the operation is performed 
with full antiseptic precautions, the wound should now be dressed pre- 
cisely as after ovariotomy. 

Subsequent Management. — Into the subsequent treatment it is 
unnecessary to enter at any length, since it must be regulated by general 
principles, each symptom being met as it arises. It has been customary 
to administer opiates freely after the operation ; but they seem to have 
a tendency to produce sickness and vomiting, and ought not to be 
exhibited unless pain or peritonitis indicates that they are required. 
In fact, the treatment should in no way differ from that usual after 
ovariotomy, and the principles that should guide us will be best shown 
by the following quotation from Sir Spencer AVells' description of that 
operation : " The principles of after-treatment are — to obtain extreme 
quiet, comfortable warmth, and apply perfectly clean linen to the patient ; 
to relieve pain by warm applications to the abdomen, and by opiate 
enemas ; to give stimulants when they are called for by failing pulse 
or other signs of exhaustion ; to relieve sickness by ice, or iced drinks; 
and to allow plain, simple, but nourishing food. The catheter must 
be used every six or eight hours, until the patient can move without 
pain. The sutures are removed on the third day,[ J ] unless tym- 
panitic distention of the stomach or intestines endangers reopening 
of the wound. In such circumstances they may be left for some days 
longer. The superficial sutures mav remain until union seems quite 
firm." 

Porro-Caesarean Operation. — Within the last few years an im- 
portant modification of the Cesarean section has been adopted, which 
is generally known as Porro's operation, from Professor Porro, of 
Pavia, who was the first European surgeon who practised it. In this 
operation, after the uterus is emptied, the entire organ is drawn out of 
the abdominal wound and excised, its neck being first constricted so as 
to suppress hemorrhage, the stump being fixed externally in the manner 
of the pedicle in ovariotomy. The idea is by no means new. It 
appears to have been first suggested by an Italian — Dr. Cavallini — in 
1768. In 1823 the late Dr. Blundell made the same proposal, and 
fortified it by experiments on pregnant rabbits, in the course of which 
he found that he lost all by the Caesarean section, but saved three out 
of four in which he ligatured and amputated the uterus. The sug- 
gestion was not, however, carried into actual practice until Dr. Storer, 
of Boston, in 1869, removed the uterus in a case of fibroid tumor 
obstructing the pelvis and impeding delivery. 

[* Sutures after Cesarean section should remain from seven to ten days ; even after eight days 
the abdominal wound has been reopened by coughing, and death has followed.— Ed.] 



550 OBSTETRIC OPERATIONS. 

Since Porro's first case, the operation has been frequently performed 
on the Continent, with results which are, on the whole, encouraging. 
The cases have been carefully tabulated by Dr. Harris, of Phila- 
delphia, who had collected up to the end of 1891, 442 cases occurring 
in the previous sixteen years, with 167 deaths of women and 99 of 
children. [ L ] This is an improvement on the former figures, when the 
mortality was 50.6 per cent. 2 [This record reduces it below 40 per 
cent. — Ed.] The obvious advantage of this plan is, that instead of 
leaving the incised uterus, with its possibly gaping wound and all the 
attendant risk of septic mischief, in the abdominal cavity, it is fixed 
externally, and in a position where it can be readily dressed. 

The objection is that it entirely unsexes the patient; but in the class 
of women requiring the Csesarean section from pelvic deformity, it is 
questionable whether this can be fairly considered as a drawback. It 
is perhaps not justifiable to attempt as yet any positive decision as to 
the indications for this plan. It certainly seemed at first to be less 
dangerous than the Cesarean section, but the improved results recently 
obtained in the latter operation have shown how it affords the patient 
as good, if not a better chance, without permanent mutilation, and 
Porro's operation probably requires for its skilful performance a more 
extensive experience in abdominal surgery. "Jt seems probable, 
therefore, that in future the Porro operation will be chiefly adopted 
when for some reason, such as the existence of nbro-myomata, the 
ablation of the uterus is specially indicated." 

The operation in the successful cases has been performed with full 
antiseptic precautions, and the neck of the uterus, after the organ is 
emptied, carefully secured by ligatures before its body is amputated. 
Some operators have encircled the neck of the uterus with a chain or 
wire ecraseur before removing it, and by this means completely con- 
trolled hemorrhage. The late Dr. Elliot Richardson 3 transfixed the 
neck of the uterus with two large pins crossing each other, before re- 
moving the wire of the ecraseur, and encircled them with stout carbo- 
lized cord. Mliller, of Berne, has recommended that the entire uterus 
should be turned out of the abdominal cavity through a long incision, 
before it is emptied, so as to avoid the risk of its fluid contents entering 
the abdomen; but this manoeuvre has not always proved feasible. The 
pedicle has generally been fixed in the lower angle of the abdominal 
wound and dressed antiseptically. In most cases one or more drainage- 
tubes have been used, either through Douglas's space or in the abdom- 
inal wound. 

Erank 4 recommends a modification of this operation, in which the 
uterus is amputated through the vagina. After incising the uterus and 
removing the child, he inverts the uterus and applies an elastic liga- 
ture round it and the ovaries outside the vagina. He now closes the 
abdominal wound, as in ovariotomy, and subsequently amputates the 
uterus below the ligature, separating and sewing the peritoneum over 

[ l The mortality under the last 100 recorded was 14.— Ed.] 

2 See Godson on Porro's Operation, Brit. Med. Journ., 1884, and note to 7th ed., vol. ii. p. 243. 

3 Amer. Journ. of Med. Sciences, 1881. 
* Arch. f. Gynak., Bd. xl. S. 117. 



CJSAREAX SECTION. 551 

imp. The operation s said - and e mt of 

the eig 

[The Caesarean Section of 1893. — I: may be of interest to go 

back fifty or sixty years .note the opinions then held, an<i - - 

- of mortality then made : but it will be much more profitable 

to consider what has done in the last and what is being 

te now. 

One of the _ si les 1 - ess in the operation has been a 

m it. beca - its fatality: and this dread of tht- iss 

has tor in determining the measure of its danger. 

sh opinion has, until quite recently, had much to do with niould- 

:' our own st fcri - irg as ; but thanks to recent so sses 

in America and Continental Europe, we are beginning to think more 

independently, and to look upon this form of delivery with far Less 

anxiety and fear than formerly. 

Even Great Britain, through her younger accoucheurs, has reeently 

shown signs of a ehange of base, under the influence of the already 

quoted su sses : Murdoek Cameron, which will be much more 

it than the still better results in Leipzig, Dresden, and Vienna. 

becans I me. 

In our own country we are slowly doing better, and the work of the 
last three years August, 1890, to August, 1893) shows a record of 28 
uses, : foui en and four children lost. Thes 

labors respe t; vely of twelve days, seven days, three days; and 
;tos was stillborn; one v - ~ered in a dying state; a third 

: months' gestation, but alive: and the fourth lived tw< 
Three of these infants were the offspring of mothers who were also 
lost 

One thin. an be certain of, i. e., that but few women will die 

in this country as a result of the Oaesai n sration under good 
hands, where there is good ground upon which t ase a : :rable 
prognosis. In the cases of eighth r here I made this estimate, 

there was not one that terminated latally. In one, labor had just 
begun : in another it had lasted a few hours, with slight pains ; in two, 
it was in nd in four, it had not coiunieneed. We have opera- 

tors in Xew York. Philadelphia, and Baltimore who are conv 
that the operation, perfornied a lew days prior to the time for labor to 
set in. has advantag js t t the hour is determined 

by the commencement of parnirition. The fear that the cervix may 
be sufficiently patulous for drainage, or that the uterus will not 
properly contract, appears to be groundle--. It must a very ex- 

1 It may interest the leader to learn the views of my American editor, Dr. Harris, of Philadel- 
phia, on this subject. It is well known that Dr. Harris has devoted an immense amount of time 

i.- i . ":•;:": :'z-. -: :.z~ : : :z-:--. :~-_:-\r. ;zi. -:n :-'z : . '--_--- —--7 '--- '.-\-z-z, :•: ";e •: z- ::•::.- rr. •::: • 
z.z~--i i-;:: rivl^ Hr-.v'-: '"r" '• -z-t- :i;.: :z: r::z~ ::--.-.::: z v.-::.. : _z \ . - ::': :/::.;:■-. zz--: 
with better success than * the conservative,' in Great Britain, from the met that the last r 
in order have recovered. Holding the views there generally advocated, the section win only be 
made in badly deformed rhachitic d warts and in the subjects of malacostecn. which are much more 
frequently thus delivered than the former. These will probably do better under the e^ 
method, which besides has the advantage that it sometimes cures malacosteon, as shown by the 
results in Continental Europe." — Harris, note to seventh American edition. 

{The remarkable successes (1888-1893) of Dr. Murdoek Cameron, of Glasgow, have set this opinion 
aside. The Potto operation should be elected in cases of osteomalacia, as the disease has been 
arrested by it in a number of instances.— Ed.] 



552 OBSTETRIC OPERATIONS. 

ceptional case where this organ is not excited to action by incising its 
wall. We have only to look at the effect of Csesarean horn-rips, to 
determine the action of the uterus when it is opened before labor. 

What is wanted in England, and especially in London, is more 
hopefulness in the operation, and this can only be begotten by a 
careful examination of the record of the past decade. Let someone 
collect the cases, and present the causes of success and failure ; and it 
will soon be learned how death is to be avoided. The death-rate in 
London is placed conjecturallv at 50 per cent.; but it should be 
known what it is positively. If it is as much as one-half, it can cer- 
tainly be reduced. Recently a rhachitic primipara from Yorkshire, of 
four feet six inches, was operated upon in Philadelphia, and is now 
rapidly recovering. We expected to save her and her child, and are 
not surprised at the result. If this can be attained here, upon an 
English woman, why not in London? It should be borne in mind 
that a very short labor is often the key-note to a recovery and a saved 
foetus. 

Sanger, of Leipzig, and his followers in Germany, Austria, and 
America, have shown the capabilities of Cesarean surgery where the 
cases are treated antiseptically and the uterine wound closed by mul- 
tiple suturing of silk. Ovarian exsection has largely removed the old 
fear of coeliotomy ; and we know now that if the mother and child 
are in a hopeful condition, skill and care will usually avail to save 
both. There need be no fear that the uterine wound will not readily 
heal, for it has been found well closed, in a case' that died in twenty- 
six hours, in Philadelphia, from conditions existing prior to the opera- 
tion. There is nothing in the idea that the process of involution in 
the uterus is antagonistic to that of union by the first intention. 
When the uterine wound was not closed, or when it was sutured with 
catgut, gaping often took place, but it does not do this now, where the 
individual tension is made light by being divided among many sutures 
of carbolized silk. It is not required to use fifty stitches, as has been 
done in a few instances, but a dozen each of deep and superficial will 
make a good average. A dozen or even less of deep stitches alone 
have answered in the Cameron cases ; but we prefer the example of 
Leipzig and Dresden, where the maternal loss has been 7J per cent. 
It should be remembered that a uterus heals the most readily whose 
muscular fibres have not been overtaxed and injured by long-con- 
tinued and fruitless action, and it should be borne in mind that anaemia 
from hemorrhage, a dead foetus in utero, and the exhaustion of long 
labor, favor the production of sepsis, septic peritonitis, and fatal shock. 
Where the uterus contains a decomposing foetus, the Porro exsection 
should be performed as the only hope of ayoiding death by septic 
absorption ; cures have been secured in this way under very desperate 
conditions. — Ed.] 



CCELIO-ELYTROTOMY. 553 



CHAPTEE VII. 

CCELIO-ELYTROTOMY [ J ] AND SYMPHYSEOTOMY. 

Bearing in mind the great mortality attending the Cesarean sec- 
tion, it is not surprising that obstetricians should have anxiously con- 
sidered the possibility of devising substitutes which should afford the 
mother a better chance of recovery. Two proposals of this kind have 
been suggested, and from both great results were anticipated. 

Coelio-elytrotomy. — One of these is the operation of coelio-elytrot- 
omy as perfected by Thomas, of Xew York, in 1870. For some 
years subsequent to that date it attracted considerable attention and 
was frequently performed. The results were on the whole promising : 
out of fourteen cases, seven mothers recovered and nine children were 
born alive ; and there was good reason to expect a still higher success 
as the technique of the operation was perfected and greater experience 
was acquired in its performance. The improved Cesarean section and 
Porro's operation have, however, of late years shown such good re- 
sults that coelio-elytrotomy has fallen into disfavor. It does not 
appear to have been performed since 1887, and as it is a complex and 
difficult procedure it is not likely again to be adopted ; nor, with the 
lessened mortality of the Cesarean section, is there any reason why it 
should be. I, however, retain the account of it as a matter of obstetric 
interest. 

History. — The earliest suggestion of a procedure of this character 
seems to have been made by Joerg in the year 1806, who proposed a 
modified Cesarean section without incision of the uterus, by the divi- 
sion of the linea alba and of the upper part of the vagina, the foetus 
being extracted through the cervix. This suggestion was never car- 
ried into practice, and it is obvious that it misses the one chief advan- 
tage of coelio-elytrotomy, the leaving of the peritoneum intact. In 
1820 Ritgen proposed and actually attempted an operation much 
resembling Thomas's, in which section of the peritoneum was avoided. 
He failed, however, to complete it, and was eventually compelled to 
deliver his patient by the Cesarean section. In 1823, Baudelocque 
the younger, independently conceived the same idea, and actually car- 
ried it into practice, although without success. Lastly, in 1837, 
Sir Charles Bell suggested a similar operation, clearly perceiving its 
advantages. Hence it appears that previous to Thomas's recent work 
in the matter, the operation was independently invented no less than 
three times. It fell, however, entirely into oblivion, and was only 
occasionally mentioned in systematic works as a matter of curious 
obstetric history, no one apparently appreciating the promising char- 
acter of the procedure. 

D From koilia, the abdomen ; elytron, the vagina, and tomse, to cut.— Ed.] 



554 OBSTETRIC OPERATIONS. 

In the year 1870, Dr. T. Gaillard Thomas, of New York, read a 
paper before the Medical Association of Yonkers, entitled " Gastro- 
elytrotoruy, a Substitute for the Cesarean Section," in which he de- 
scribed the operation as he had performed it three times on the dead 
subject, and once on a married woman in 1870, with a successful issue 
as regards the child. It seems beyond doubt that Thomas invented 
the operation for himself, being ignorant of Eitgen's and Baudelocque's 
previous attempts, and it is certain, to quote Garrigues, 1 that to him 
"belongs the glory of having been the first who performed ccelio- 
elytrotomy so as to extract a living child from a living mother in his 
first operation, and of having brought both mother and child to com- 
plete recovery in his second operation." 

Since Thomas's first case, the operation has been j>erformed several 
times in America, and has found its way across the Atlantic, having 
been twice performed in England, by Himes in Sheffield, by Edis in 
London ; and by Poullet in Lyons, France. 

Nature of the Operation. — The object of ccelio-elytrotoruv is to 
reach the cervix by incision through the lower part of the abdominal 
wall and upper part of the vagina, and through it to extract the foetus 
as may most easily be done. 

Advantages over the Ceesarean Section. — The advantages it 
offers over the Cesarean section are that in dividing the abdomen the 
abdominal wall only is incised, and the peritoneum is left intact. The 
vagina is divided, but incision of the uterine parietes, which forms 
one of the chief risks of the Cesarean section, is entirely avoided. 

Cases Suitable for the Operation. — It may be broadly stated that 
ccelio-elytrotomy is applicable in all cases calling for the Cesarean section 
when the mother is alive. In post-mortem extractions of the foetus, 
the Csesarean section, being the most rapid procedure, would certainly 
be preferable. Exceptions must be made for certain cases of morbid 
conditions of the soft parts which render delivery per vias naturales 
impossible; and in which ccelio-elytrotomy could not be performed, as in 
cases of tumor obstructing the pelvic cavity, also in carcinoma and fibroid 
of the uterus. AVhen the head is firmly impacted in the pelvic brim, and 
cannot be dislodged, the operation would be impossible, as the vagina 
could not be incised. Unlike the Csesarean section, the operation can- 
not be performed twice on the same patient, at least on the same side, 
since adhesions left by the former incisions would prevent the separa- 
tion of the peritoneum and division of the vagina. It remains to be 
seen whether in certain cases of extreme deformity, with pendulous 
abdomen and distorted thighs, the site of incision might not be so 
difficult to reach as to render the necessary manoeuvres impossible. 

Anatomy of the Parts concerned in the Operation. — It will 
facilitate the proper comprehension of the operation, and render an 
avoidance of its possible dangers more easy, if the anatomical relations 
of the parts concerned arebriefiy described. 

The abdominal incision extends from a point an inch above the 
anterior superior iliac spine, and is carried, with a slight downward 

1 New York Med. Journ., 1878, vol. xxviii. pp. 337, 449. 



CCELIO-ELYTROTOMY. 555 

curve, parallel to Poupart's ligament until it reaches a point one inch 
and three-quarters above, and to the outside of, the spine of the pubes. 

Beyond the latter point it must not extend, so as to avoid the risk of 
wounding the round ligament and the epigastric artery. ]n this incision 

the skin, the aponeurosis of the external oblique, and the fibres of the 
internal oblique and transversalis muscles are divided. The rectus is 
not implicated. After tbe muscles are divided the transversalis fascia 
is reached. It is fortunately rather dense in this situation, and is 
separated from the peritoneum by a layer of eonnective tissue con- 
taining fat. 

The superficial epigastric artery is necessarily divided, but is too 
small to give any trouble. The internal epigastric is fortunately not 
divided, but is so near the inner end of the incision that it may acci- 
dentally be so. In one of Dr. Skene's operations it was laid bare. 
Starting from the external iliac, about a quarter of an ineh above 
Poupart's ligament, it runs downward, forward, and inward to the 
ligament, thence it turns upward and inward, in front of the round 
ligament and to the inner side of the internal abdominal ring, behind 
the posterior layer of the sheath of the rectus muscle, which it finally 
enters. The circumflex iliac artery also rises from the external iliac a 
little below the epigastric. It runs between the peritoneum and Pou- 
part's ligament until it reaches the crest of the ilium, to the inner side 
of which it runs. It thus lies altogether below the line of the incision, 
and is not likely to be injured. 

After the transversalis fascia is divided the peritoneum is reached, 
and is readily lifted up intact, so as to expose the upper part of the 
vagina, through which the foetus is extracted. It is fortunate, as facili- 
tating this manoeuvre, that the peritoneum is much more lax than in 
the non-pregnant state, and it has been found very easy to lift it out of 
the way in all the operations hitherto performed. 

The division of the vagina is the part of the operation likely to give 
rise to most trouble and risk. It is to be noted that, in cases of pelvic 
contraction calling for this operation, the uterus, with its contents, will 
be abnormally high and altogether above the pelvic brim ; the vagina 
is, therefore, necessarily elongated and brought more readily within 
reach. It is enlarged in its upper part during pregnancy, and thrown 
into folds ready for dilatation during the passage of the child. It is 
loosely surrounded by the other tissues, and is composed of muscular 
fibres, easily separable, and an internal mucous layer. Its vascular 
arrangements are very complex, and the risk of hemorrhage is one of 
the prominent difficulties of the operation. 

In Baudelocque's attempt, in which the vagina was cut instead of 
torn, the loss of blood was so great as to lead to a discontinuance of the 
operation. The arteries are numerous, consisting of branches from the 
hypogastric, inferior vesical, internal pudic, and hemorrhoidal. The 
veins form a network surrounding the whole canal, but are largest at its 
extremities, so that it is desirable to open the vagina as low down as 
possible. 

Behind the vagina lies the pouch of peritoneum known as Douglas's 
space, and below that the rectum. In front of it lies the bladder, and 



556 OBSTETRIC OPERATIONS. 

the risk of injuring that viscus or the ureter entering it constitutes 
another of the dangers of the operation. The relations of these parts 
have been specially studied by Garrigues, 1 with the view of facili- 
tating the safe performance of the operation, and I quote his descrip- 
tion : 

"The anterior superior surface of the vagina is. in its upper part, 
bound by loose connective tissue to the bladder on a surface that has 
the shape of a heart. In the lower or anterior part, the boundary line 
of this surface runs parallel to, and a little outside of, the trigonum 
vesicate. In the upper part it follows the outline of the vagina, from 
which it passes over to the cervix. The distance from the internal 
opening of the urethra to the neck of the womb is one inch and a 
quarter (3.2 centimetres). The bladder extends five-eighths of an inch 
(1.5 centimetres) upon the cervix. It is very liable to be reached by 
the vaginal rent, if the latter is made too high up or too horizontal. 
The lower part of the antero-superior wall carries in the middle line 
the urethra. In the uppermost part, a little outside of and behind the 
bladder, lies the ureter. In order to avoid the ureter and the bladder, 
the incision of the vagina should be made nearly an inch and a half 
(3.8 centimetres) below the uterus, and in a direction parallel to the 
ureter and the boundary line between the bladder and the vagina." 

The Operation. — The operation has hitherto been performed chiefly 
on the right side. In consequence of the position of the rectum on the 
left, it seemed doubtful if the difficulties of performing it on that side 
would not render the operation impossible. It has, however, been 
performed three times on the left side, and apparently as easily as on 
the right. For the proper performance of the operation four assistants 
are necessary, besides one who administers the anaesthetic. The patient 
is placed on her back on the operating-table, with the pelvis raised 
and in the same position as for ovariotomy. In consequence of access 
of air per vaginam strict antiseptic precautions cannot be adopted. 
Before commencing the operation the cervix is dilated as much as 
possible by Barnes's bags, assisted, if necessary, by digital dilatation. 

The operator stands on the right side of the patient, while an 
.assistant, standing on her left, lays his hand on the uterus and draws 
it upward and to the left, so as to put the skin on the stretch. The 
incision is commenced at a point one inch above the anterior superior 
spine of the ilium, and is carried inward in a slightly curved direction 
until it reaches a point one and three-quarters inches above and outside 
the spine of the pubes. The skin, muscular aud aponeurotic tissues 
are carefully divided, layer by layer, any arterial branches being 
secured as they are severed, until the trans versalis fascia, is reached. 
This is raised by a fine tenaculum, and an aperture is made in it 
through which a director is introduced, and on this the fascia is divided 
in the whole length of the superficial incision. The operator now sepa- 
rates the peritoneum from the transversalis and iliac fascia with his 
fingers, and an assistant, placed on his left, elevates it, as well as the 
contained intestines, by means of a fine warmed napkin, and keeps it 

1 Loc. cit., p. 479. 



SYMPHYSEOTOMY. 557 

well out of the way during- the rest of the operation. A third assistant 

now introduces a silver catheter into the bladder, and holds it in the 
position of the boundary line between it and the vagina, and below the 
uterus. 

A blunt wooden instrument like the obturator of a speculum is 
introduced into the vagina, which is pushed up by it above the ilio- 
pectineal line. On this an incision is made by Paquelin's thermo- 
cautery heated to a red heat only, as far below the uterus as possible, 
and parallel to the ilio-pectineal line and the catheter felt in the 
bladder. When the vagina has been burnt through, the index fingers 
of both hands are pushed through the incision, and the vagina torn 
through as far forward as is deemed safe by the guide of the catheter 
in the bladder, and as far backward as possible. AVhen this has 
been done the uterus is depressed to the left, and the cervix lifted 
into the incision by the fingers, and the membranes are ruptured. 
Through the cervix thus elevated the child is extracted, according to 
the presentation, either by simple traction, by the forceps, or by turn- 
ing. Before concluding the operation the bladder should be injected 
with milk to make sure that it has not been wounded. Should it be 
so, the laceration may be at once united by carbolized gut. The prin- 
cipal risk at this stage is hemorrhage from the vaginal vessels, which, 
however, fortunately did not give rise to much trouble in any of the 
recent operations. If it occurs it must be dealt with as best Ave can, 
either by ligature, by the actual cautery, or by thoroughly plugging 
the vaginal wound with cotton both through the incision and per 
vaginam. If the latter be not necessary, the wound should be cleaned 
by injecting a warm solution of weak carbolized water (2 per cent.), 
its edges united by interrupted sutures, and dressed as is deemed best. 
The subsequent treatment must be conducted on general surgical 
principles, and will much resemble that necessary after other severe 
abdominal operations, such as ovariotomy. The vagina should be 
gently syringed two or three times daily with a weak antiseptic lotion. 
The diet should be light and nutritious, chiefly consisting of milk, beef- 
tea, and the like. Pain, pyrexia, etc., must be treated as they arise. 

Symphyseotomy. — The second operation requires a more extended 
notice than in former editions of this work, since it has been revived 
within the last few years, chiefly under the auspices of Professor Mori- 
sani, of Xaples, and has now been performed in a large number of 
cases, as an alternative to craniotomy, " and with very considerable 
success. 

Its History. — In 1768 Sigault, then a medical student in Paris, 
suggested symphyseotomy, which consists in a division of the symphysis 
pubis, with a view of allowing the pubic bones to separate sufficiently 
to admit of the passage of the child. f 1 ] Although at first strongly 
opposed, it was subsequently ardently advocated by many obstetricians, 
and frequently resorted to on the Continent. In 1778 the operation 
was performed thirteen times in Germany, France, and Belgium; once 
only in England, in 1782. Since that time it gradually fell into dis- 

[ > The proposition was made originally in the work of Severin Pineau, which he is known to 
have had.— Ed.] 



558 OBSTETRIC OPERATIONS. 

favor, and may be said to have become practically obsolete, a few cases 
only having occasionally been operated on in Italy, where suitable 
cases of pelvic deformity appear to be very common. In 1863 Prof. 
Morisani, of Naples, undertook a study of the operation on the dead 
subject, and came to the conclusion that it had a sound basis, and 
in 1866 he operated on a living woman, saving both the mother and 
child. Since January 1, 1886, it had been performed, up to the end 
of 1892, in 115 cases in Europe and America, with 9 maternal deaths 
and 24 children lost. Up to this time it has been attempted but once 
each in Ireland and England. 

These figures are certainly very striking, and the remarkably dimin- 
ished mortality is beyond doubt due to the application of careful anti- 
sepsis and improved technique. The maternal mortality will certainly 
contrast favorably with that attending an equal number of severe 
craniotomies, in all of which the children would have been sacrificed. 
It is to be noted, however, that this operation can never take the place 
of the Cesarean section in extreme cases of pelvic deformity, but is 
rather a substitute for craniotomy in slighter cases, chiefly in flattened 
pelves, which are just too small to admit of the passage of a living 
child. It is not applicable in cases of obliquely contracted pelvis, or 
in cases in which delivery is obstructed by tumors of any kind, bony 
growths, or carcinoma. It has also been suggested in certain cases in 
which the head is impacted in consequence of malpresentation, such as 
mento-posterior positions of the face, or in brow presentations, in which 
craniotomy would otherwise be necessary. 1 Any alternative that will 
avoid the destruction of a living foetus is surely well worthy of con- 
sideration, and there can be little doubt that the recent happy results 
following the revival of symphyseotomy will lead to its adoption in 
suitable cases. The operation itself is by no means difficult, and it 
requires less surgical skill than the Cesarean section, or Porro's opera- 
tion, or a difficult craniotomy. 

Limits of the Operation. — Professor Morisani lays down two and 
five-eighths inches as the limits below which symphyseotomy is im- 
practicable. It would, of course, be a matter of great moment to 
ascertain the exact dimensions of the sacro-pubic diameter accurately, 
whenever the operation is contemplated, but as the necessity for this 
may not arise until the patient is actually in labor, this may not always 
be practicable. It is, however, in cases with a conjugate larger than 
this, in which we would otherwise be obliged to resort to perforation, 
that this alternative will most frequently present itself in the hope of 
saving the life of the child. It is in such cases as the following, 
quoted by Harris, in which the contraction is not excessive, that sym- 
physeotomy will probably find its best application : " The patient was 
in labor for the third time. Her first child having been a large one, 
perished ; the second being much smaller, lived ; and the third was 
again too large to pass. She had a diagonal conjugate of 100 milli- 
metres (four inches), and probably three and three-quarters inches in 
the true conjugate. The foetus, which was arrested at the superior 

1 "Symphyseotomy -a Successful Case," by J. Edwiu Michael, M.A., M.D. Amer. Journ. of 
Obstet., February, 1893, p. 183. 



SYMPHYSEOTOMY. 



559 



strait, was delivered in fifteen minutes, by the vertex under manual 
assistance, alter her pubes had been opened by the knife. The child 



Fig. 200. 




Fig. 201. 




^ mat SIZE 

Sections of pelvic brim to illustrate symphyseotomy. (After Pinard.) 

was saved instead of perishing under the perforator ; the mother made 
a good recovery, and was well in thirty days." 

Having no personal experience of this operation, I can give no 
opinion on its merits, beyond the obvious remark that anything that 



560 OBSTETRIC OPERATIONS. 

tends to minimize the resort to the horrible operation of craniotomy, 
without materially increasing the risk to the mother, which the figures 
so far show that this operation promises to do, is well worthy of the 
most serious study and consideration. 

The accompanying diagrams (Figs. 200, 201) will give an idea of 
the increased pelvic dimensions obtained by symphyseotomy. It rep- 
resents sections at the pelvic brim made on a subject who had died 
nine days after delivery at term. After division of the symphysis a 
separation of three inches took place, which is the average amount to 
be expected, and this gives about an inch gain on all the pelvic diam- 
eters. This increase is well illustrated by the second figure, which 
shows the same section with the pubic bones placed in contact. 

Description of the Operation. — The operation itself is very simple. 
I cannot describe it better than in the words of Dr. Harris : 

" The armamentarium required is very simple, viz. : a scalpel ; 
Galbiati's probe-pointed sickle-shaped bistoury 1 (Fig. 202) ; some 
haemostatic forceps ; a needle-holder and needles ; a metallic catheter ; 
ligature silk ; gauze and cotton. After sterilizing these, place the 
parturient woman on her back, on an operating-table, with her knees 

Fig. 202. 




Galbiati's sickle-shaped bistoury. 

drawn up and separated, shave the nions Veneris and labia majora, 
and disinfect the supra-pubic region, the vulva, the perineum, and 
vulvo-vaginal canal. Examine the depth, thickness, and direction of 
the symphysis, and search out the fossa in its superior edge which 
marks the point of union of the two pubic bones; then examine the 
inferior margin and the anterior and posterior faces of the pubes. 

" Introduce the female catheter and give it into the hand of an 
assistant, that he may depress the urethra from the pubic arch, and at 
the same time carry it to the right side, to save it from injury. Make 
a vertical incision through the skin and fat above the pubes, about 
two to two and one-half inches in length, ending about three-fourths 
of an inch above the symphysis, cutting the tissues gently and passing 
in a line down to the insertion of the recti muscles. Detach for a 
short space the recti muscles from their attachment to the two ossa 
pubes ; introduce the left index finger into the opening, and separate 
the retro-pubic tissue. Then apply the palmar face of the finger directly 
against the posterior face of the symphysis, hooking with it the in- 
ferior margin of the articulation, while the assistant attends to the' 
catheter as stated. The operator then introduces the Galbiati bistourv 
and hooks it around the articulation, cutting the interosseous ligaments 

1 An ordinary probe-pointed curved bistoury may be used instead of this special knife. 



SYMPHYSEOTOMY. 561 

and cartilage from within outward and below upward. When the 
section has been completed it will be known by a creaking sensation 
and a separation of the bones from one and one-quarter to one and 
one-half inches. 

"After this step, cover the wound with the gauze, dipped in a 
bichloride solution of 1 : 4000, and attend to the delivery of the foetus, 
having at the same time the separation of the innominata antagonized 
by pressure with the hands of assistants. During the passage of the 
head ascertain the amount of pubic separation ; spray the vagina ; and 
when the placenta is delivered, introduce six or eight interrupted silk 
sutures into the edges of the wound ; dress it with sublimated cotton, 
1 : 2000, and bandage the pelvis and lower extremities." 

Pinard 1 prefers to divide the pubes from without inward with a 
straight bistoury, protecting the subjacent structures with the index 
finger of the left hand previously passed behind it. 

One would naturally fear that after the section of the symphysis, 
and the strain put on the sacro-iliac joints by the separation of the in- 
nominate bones, subsequent difficulties in locomotion would arise. No 
mention is made of this in the cases hitherto published, but the point 
appears to require further investigation^ 2 ] 

[Fig. 203. 




Harris's symphyseotomy bistoury. This is modelled to conform with the posterior curve of the 
symphysis from above downward.— Ed.] 

After the incision is made and the symphysis separated, it may, of 
course, be necessary to complete delivery either by the high forceps 
operation or by version. 

[Progress and Results of Symphyseotomy. — Until February 4, 
1892, this operation was for many years confined to Italy, and for 
twenty-seven years almost entirely to ^Naples, in which city there were 
twelve women delivered under it in 1891. On the date mentioned it 
reappeared in Paris, and soon commenced to be performed in other 
countries ; but not with the success that had attended it in Italy 
during 1886-91. Although originally a French operation, it had 
fallen into very bad repute, and had for many years been considered 
as beyond the pale of obstetric surgery. In its restoration to favor it 
again became the operation of Sigault, and was performed by direct 
incision, and not by the sub-osseous method, which under Morisani 
and Xovi, of Xaples, in an experience of twenty-six years (1866-91), 
had procured it a reputation of success and safety. The successes of 
Pinard, of Paris, gave the method a new impetus, and it has rapidly 
spread into other countries, where it has been performed with varying 
success ; but in no locality with the low death-rate of Italy, where 46 

1 Symphyseotomy at the Clinique Baudelocque, Lancet, February 18, 1893. 
[ 2 Difficulty in locomotion has very rarely followed the operations under antisepsis and pelvic 
fixation, and the disability has been* temporary.— Ed.] 

36 



562 OBSTETRIC OPERATIONS. 

deliveries cost the lives of onlv 2 women and 5 children, dating from 
1886. 

Although Prof. Pinard did not lose a case until his twentieth died 
of direct sepsis, no other operator or country out of Naples had this 
measure of success. France lost 5 out of her first 35, including 8 
successes of Pinard ; and the United States lost 4 out of her first 25. 
In sixteen months (February 1, 1892, to June 1, 1893) the operation 
was tested in eleven countries and upon more than 150 women. 

If we include the Italian operations of 1886-91, we find that, up to 
June of this present year, there were 25 women and 37 children lost 
under 205 syinphyseotoinic deliveries, according to the record made 
by Neugebauer, of Warsaw, with my assistance. This would leave, 
without the 46 of Italy, 23 deaths in 159 women, and 32 children 
lost. Not a very encouraging record when compared with the Cesarean 
results of Leipzig and Dresden, a mortality of 7 per cent. 

Symphyseotomy, although an old operation, is still in the experi- 
mental period of its existence in all localities outside of Naples, and 
we should, in our country at least, be content to follow the directions 
given by Morisani, as already stated. Several prominent operators 
have been very much disappointed with the results attained in their 
hands, while others, more successful, are disposed to commend the 
method. In our own country it is believed to have a promising future ; 
to secure which the operation by direct incision is to be avoided, as the 
results in France and Vienna do not commend it. 

Having for twelve years studied this operation by correspondence, 
I am inclined to regard it in the light of its measure of possibility, as 
shown by the work of the last six and one-half years in Naples, rather 
than by the actual average of success elsewhere in the past eighteen 
months. There does not now appear to be any element of danger 
arising from injury done to the sacro-iliac synchondroses. What they 
have most to fear in Continental maternities is septic poisoning from 
the wound in the symphysis, or from lacerations of the cervix, vagina, 
vulva, and perineum, all of which sometimes occur in the same sub- 
ject, and particularly in rhachitic primiparse. It should be borne in 
mind that in cases where the pelvis is much contracted, the vagina and 
vulva will usually be found to be of the same character, and an oper- 
ator cannot be too cautious in making slow and interrupted traction 
with his forceps. 

The minimum conjugate diameter of Morisani of two and five- 
eighths inches is too small for this country, where the foetus is on the 
average of larger size, and should be fixed at two and three-quarters 
inches ; and even this will be found a dangerous measure where the 
foetus is a male and above the average weight. If a Avoman is oper- 
ated upon in good season, and by the sub-osseous section, she should 
run but a moderate risk for her life, and her child likewise ; although 
the latter has a less decree of safetv. According to Dr. Franz Neu^e- 
bauer, the general average of death for the women is now 12 per cent., 
and for the children, 18. In the United States the average has been, 
respectively, 16 per cent, and 24 per cent. This statement has dis- 
appointed many of our accoucheurs ; but if they will examine into the 



SYMPHYSEOTOMY. 563 

causes of death in the four women, they will find encouragement rather 
than the reverse. Like the Caesarean section, much will depend upon 
the length of labor and the condition of the patient when operated on 
for securing a successful issue. Symphyseotomy ought to be less 
dangerous than the Caesarean section lias been in our country; and 
nothing short of this should satisfy those who propose to substitute it 
for craniotomic infanticide. It is a less formidable operation, and 
women make less objection to it than they do to the abdominal delivery. 
It requires less skill in its execution, and is not so shocking in its 
effects upon the nerves of the accoucheur; but take the whole delivery 
in many cases, and it will be found that no little skill is required to 
secure a favorable result. 

Operation after Induced Labor. — Where the true conjugate is 
below the minimum measure, the disproportion between it and the 
size of the foetal head may be overcome by bringing on labor at the 
end of the eighth month or a little later. Children thus delivered 
require extra care in raising, and in the class to which they belong are 
very often lost at an early period. In exceptional instances they have 
done remarkably well ; but it is a question to be considered, whether 
it would not be better in the average of cases to deliver by the Caesarean 
section at full term. 

Unilateral Ischio-pubiotomy. — Following a suggestion of Fara- 
beuf, Prof. Pinard operated upon a V-para of thirty-two at the Clin- 
ique Baudelocque on November 9, 1892, so as to deliver a living male 
foetus, weighing nearly nine pounds, through an oblique Naegele pelvis. 
He cut down upon the isehio-pubic ramus of the ankylosed side, and 
divided it with a chain-saw ; and repeated a section of the horizontal 
ramus of the corresponding os pubis at a distance of 5 cm. from the 
symphysis. This enabled him to open out the front of the pelvis by 
the separation of the free synchondrosis of the opposite side under the 
traction of Tarnier's forceps ; and a separation of the os pubis to the 
extent of 4 cm. gave room for the passage of the foetus. The wound 
healed by the first intention in eight days ; the woman sat up in thirty- 
two days, and walked about without inconvenience in two months, the 
child then weighing eleven pounds. 1 This, in principle, was a repeti- 
tion of the bi-pubiotomy of Galbiati, of Naples, performed upon both 
sides on March 30, 1832, with a fatal result; the dwarf of three and 
one-half feet, having a one-inch conjugate, dying in four days. The 
operation of Farabeuf had the advantages of antisepsis, and of a 
slight disproportion of size between the pelvic canal and foetal head. 
—Ed.] 

\ Annales de Gynecol, et d'Obstet., Fev., 1893. pp. 139-152. 



564 OBSTETRIC OPERATIONS. 



CHAPTEE VIII. 

THE TRANSFUSION OF BLOOD. 

The Transfusion of Blood in desperate and apparently hopeless 
cases of hemorrhage offers a possible means of rescuing the patient 
which merits careful consideration. It has again and again attracted 
the attention of the profession, but has never become popularized in 
obstetric practice. The reason of this is not so much the inherent 
defects of the operation itself — for quite a sufficient number -of success- 
ful cases are recorded to make it certain that it is occasionally a most 
valuable remedy — but the fact that the operation lias been considered 
a delicate and difficult one, and that it has been deemed necessary to 
employ a complicated and expensive apparatus, which is never at hand 
when a sudden emergency arises. Whatever may be the difference of 
opinion about the value of transfusion, I think it must be admitted 
that it is of the utmost consequence to simplify the process in every 
possible way ; and it is above all tilings necessary to show that the 
steps of the operation are such as can be readily performed by any 
ordinarily qualified practitioner, and that the apparatus is so simple 
and portable as to make it easy for any obstetrician to have it at hand. 
There are comparatively few who would consider it worth while to 
carry about with them, in ordinary every-day work, cumbrous and 
expensive instruments which may never be required in a life-long 
practice ; and hence it is not unlikely that, in many cases in which 
transfusion might have proved useful, the opportunity of using it has 
been allowed to slip. Of late years the operation has attracted much 
attention, the method of performing it has been greatly simplified, 
and I think it will be easy to prove that all the essential apparatus 
may be purchased for a few shillings, and in so portable a form as to 
take up little or no room ; so that it may be always carried in the 
obstetric bag ready for any possible emergency. 

History of the Operation. — The history of the operation is of con- 
siderable interest. In Yillari's Life of Savonarola, it is said to have 
been employed in the case of Pope Innocent VIII., in the year 1492, 
but I am not aware on what authority the statement is made. The 
first serious proposals for its performance do not seem to have been 
made until the latter half of the seventeenth century. It was first 
actually performed in France by Denis, of Montpellier, although 
Lower, of Oxford, had previously made experiments on animals which 
satisfied him that it might be undertaken with success. In November, 
1667, some months after Denis's case, he made a public experiment at 
Arundel House, in which twelve ounces of sheep's blood were injected 
into the veins of a healthy man, who is stated to have been very well 



THE TRANSFUSION OF BLOOD. 565 

after the operation, which must, therefore, have proved successful. 
These nearly simultaneous eases gave rise to a controversy as to priority 
of invention, which was long carried on with much bitterness. 

The idea of resorting to transfusion after severe hemorrhage docs 
not seem to have been then entertained. It was recommended as a 
means of treatment in various diseased states, or with the extravagant 
hope of imparting new life and vigor to the old and decrepit. The 
blood of the lower animals only was used ; and, under these circum- 
stances, it is not surprising that the operation, although practised on 
several occasions, was never established as it might have been had its 
indications been better understood. 

From that time it fell almost entirely into oblivion, although experi- 
ment:, and suggestions as to its applicability were occasionally made, 
especially by Dr. Harwood, Professor of Anatomy at Cambridge, who 
published a thesis on the subject in the year 1785. He, however, 
never carried his suggestions into practice, and, like his predecessors, 
only proposed to employ blood taken from the lower animals. In the 
year 1824 Dr. Blundell published his well-known work entitled 
Researches, Physiological and Pathological, which detailed a large 
number of experiments ; and to that distinguished physician belongs 
the undoubted merit of having brought the subject prominently before 
the profession, and of pointing out the cases in which the operation 
might be performed with hopes of success. Since the publication of 
this work, transfusion has been regarded as a legitimate operation 
under special circumstances ; but, although it has frequently been per- 
formed with success, and in spite of many interesting monographs on 
the subject, it has never become so established as a general resource 
in suitable cases as its advantages would seem to warrant. Within 
the last few years more attention has been paid to the subject, and the 
writings of Panum, Martin, and De Belina on the Continent, and of 
Higginson, McDonnell, Hicks, Aveling, and Schafer in Great Britain, 
amongst others, have thrown much light on many points connected 
with the operation. 

Nature and Object of the Operation. — Transfusion is practically 
only employed in cases of profuse hemorrhage connected with labor, 
although it has been suggested as possibly of value in certain other 
puerperal conditions, such as eclampsia or puerperal fever. Theo- 
retically it may be expected to be useful in such diseases ; but, inas- 
much as little or nothing is known of its practical effects in these 
diseased states, it is only possible here to discuss its use in cases of 
excessive hemorrhage. Its action is probably twofold : first, the 
actual restitution of blood which has been lost ; second, the supply of 
a sufficient quantity of blood to stimulate the heart to contraction, and 
thus to enable the circulation to be carried on until fresh blood is 
formed. The influence of transfusion as a means of restoring lost 
blood must be trivial, since the quantity required to produce an effect 
is generally very small indeed, and never sufficient to counterbalance 
that which has been lost. Its stimulant action is no doubt of far more 
importance ; and if the operation be performed before the vital energies 
are entirely exhausted, the effect is often most marked. 



566 OBSTETRIC OPERATIONS. 

Use of Blood taken from the Lower Animals. — In the earliest 
operations the blood used was always that of the lower animals, gener- 
ally of the sheep. It has been thought by Brown-Sequard and others 
that the blood of some of the lower animals, especially of those in which 
the corpuscles are of smaller size than in man, as of the sheep, might 
be used with safety, provided it is not too rich in carbonic acid and 
too poor in oxygen, and injected in small quantity only. Landois, 1 
however, has conclusively proved that the blood of any of the lower 
animals has a most injurious effect on the human red corpuscles, which 
rapidly become swollen and decolorized, and discharge their coloring 
matter into the serum. It is certain, therefore, that this plan cannot 
be adopted in practice. 

The great practical difficulty in transfusiou has always been the 
coagulation of the blood very shortly after it has been removed from 
the body. AVhen fresh-drawn blood is exposed to the atmosphere, the 
fibrin commences to solidify rapidly, generally in from three to four 
minutes, sometimes much sooner. It is obvious that the moment 
fibrination has commenced, the blood is, ipso facto, unfitted for trans- 
fusion, not only because it can be no longer passed readily through the 
injecting apparatus, but because of the great danger of propelling small 
masses of fibrin into the circulation, and thus causing embolism. 
Hence, if no attempt be made to prevent this difficulty, it is essential, 
no matter what apparatus is used, to hurry on the operation so as to 
inject before fibrination has begun. This is a fatal objection, for there 
is no operation in the whole range of surgery in which calmness and 
deliberation are so essential, the more so as the surroundings of the 
patient in these unfortunate cases are such as to tax the presence 
of mind and coolness of the practitioner and his assistants to the 
utmost. 

All the recent improvements have had for their object the avoidance 
of coagulation, and practically this has been effected in one of three 
ways : First, by immediate transfusion from arm to arm, without 
allowing the blood to be exposed to the atmosphere, according to the 
methods proposed by Aveling, Roussel, and Sehafer. Second, by add- 
ing to the blood certain chemical reagents which have the property of 
preventing coagulation. Third, removal of the fibrin entirely by 
promoting its coagulation and straining the blood, so that the liquor 
sanguinis and blood corpuscles alone are injected. 

Inasmuch as the success of the operation altogether depends on the 
method adopted, it will be well, before going further, to consider briefly 
the advantages and disadvantages of each of these plans. 

Aveling-'s Method. — The method of immediate transfusion has 
been brought prominently before the profession by Dr. Aveling, who 
has invented an ingenious apparatus for performing it. The apparatus 
consists essentially of a miniature Higginson's syringe, without valves, 
and with a small silver canula at either end. One canula is inserted 
into the vein of the person supplying blood, the other into a vein of 
the patient, and by a curious manipulation of the syringe, subsequently 

1 Die Transfusion des Blutes, Leipzig, 1875. 



THE TRANSFUSION OF BLOOD. 567 

to be described, the blood is carried from one vein into the other. It 
must be admitted that if there were no practical difficulties, this instru- 
ment would be admirable, and it is, therefore, not surprising that it 
should have met with so much favor from the profession. I cannot 
but think, however, that the operation is not so simple as at first sight 
appears, and that therefore it wants one of the essential elements 
required in any procedure for performing transfusion. One of my 
objections is, that it is by no means easy to work the apparatus without 
considerable practice. Of this I have satisfied myself by asking mem- 
bers of my class to work it after reading the printed directions, and 
rinding that the}' are not always able to do so at once. Of course, it 
may be said that it is easy to acquire the necessary manipulative skill; 
but when the necessity for transfusion arises, there is not time left for 
practising with the instrument, and it is essential that an apparatus, 
to be universally applicable, should be capable of being used imme- 
diately and without previous experience. Other objections are — the 
necessity of several assistants, the uncertainty of there being a sufficient 
circulation of blood in the veins of the donor to afford a constant 
supply, and the possibility of the whole apparatus being disturbed by 
restlessness or jactitation on the part of the patient. For these reasons 
it seems to me that this plan of immediate transfusion is not so simple, 
nor so generally applicable, as defibrination. Still, it is impossible not 
to recognize its merits, and it is certainly well worthy of further study 
and investigation. 

Roussel's Method. — Another method of immediate transfusion is 
that recommended by Roussel, 1 whose apparatus has recently attracted 
considerable attention. It possesses many undoubted advantages, and 
is beyond doubt a valuable addition to our means of performing the 
operation. It has, however, the great disadvantage of being costly 
and complicated, and hence I do not believe that it is likely to come 
into general use. 

Schafer's Method. — The third method is that recommended by Dr. 
Schafer in his recent excellent reports on transfusion submitted to the 
Obstetrical Society. 2 Schafer suggests two methods of performing the 
operation : one from vein to vein, the other from artery to artery. 
The latter, he holds, has the advantage of supplying pure oxygenated 
blood, under the best possible conditions for securing the amelioration 
of a patient suffering from the effects of profuse hemorrhage. The 
necessary operative proceedings are, however, somewhat complicated, 
and it seems to me very doubtful if this plan is likely to be at all 
commonly used. His method of immediate transfusion, however, is 
very simple, and is well worthy of trial. In his experiments on the 
lower animals it answered admirably. I am not aware that it has yet 
been tried on the human subject, but I do not see any practical diffi- 
culty in its application. For the description of the operation I have 
inserted Dr. Schafer's own directions for the performance of venous 
immediate transfusion. 

The second plan for obviating the bad effects of clotting is the addi- 

1 Obstetrical Transactions for 1S"6, vol. xviii. p. 280. 

2 Ibid., vol. xxi. p. 316. 



568 OBSTETRIC OPERATIONS. 

tion of some substance to the blood which shall prevent coagulation. 
It is well known that several salts have this property, and the experi- 
ments made in the case of cholera patients prove that solutions of some 
of them may be injected into the venous system without injury. This 
method has been specially advocated by Dr. Braxton Hicks, who uses 
a solution of three ounces of fresh phosphate of soda in a pint of water, 
about six ounces of which are added to the quantity of blood to be 
injected. He has narrated four cases * in which this plan was adopted 
successfully, so far as the prevention of coagulation was concerned. It 
certainly enables the operation to be performed with deliberation and 
care, but it is somewhat complicated, and it may often happen that 
the necessary chemicals are not at hand. A further objection is the 
bulk of fluid which must be injected, and there is reason to believe 
that this has in some cases seriously embarrassed the heart's action 
and interfered with the success of the operation. In many of the 
successful cases of transfusion the amount of blood injected has been 
very small, not more than two ounces. Dr. Richardson proposes to 
prevent coagulation by the addition of liquor amnionic to the blood, 
in the proportion of two minims diluted with twenty minims of water 
to each ounce of blood. 

Defibrination of the Blood. — The last method, and the one which, 
on the whole, I believe to be the simplest and most effectual, is defibrina- 
tion. It has been chiefly practised in the British Isles by Dr. McDon- 
nell, of Dublin, who has published several very interesting cases in 
which he employed it, and on the Continent by Martin, of Berlin, and 
De Belina, of Paris. The process of removing the fibrin is simple in 
the extreme, and occupies a few minutes only. Another advantage is 
that the blood to be transfused may be prepared quietly in an adjoining 
apartment, so that the operation may be performed with the greatest 
calmness and deliberation, and the donor is spared the excitement and 
distress which the sight of the apparently moribund patient is apt to 
cause, and which, as Dr. Hicks has truly pointed out, may interfere with 
the free flow of blood. The researches of Panum, Brown-Sequard, and 
others have proved that the blood corpuscles are the true vivifying 
element, and that defibriuated blood acts as well in every respect as that 
containing fibrin. It has been proved that the fibrin is reproduced within 
a short time, 2 and the whole tendency of modern research is to regard 
it, not as an essential element of the blood, but as an excrementitious 
product, resulting from the degradation of tissue, which may, therefore, be 
advantageously removed. Another advantage derived from defibrina- 
tion is, that the corpuscles are freely exposed to the atmosphere, oxygen 
is taken up, and carbonic acid given off, and the dangers which Brown- 
Sequard has shown to arise from the use of blood containing too much 
carbonic acid are thereby avoided. There can be, therefore, no physi- 
ological objection to the removal of the fibrin, which, moreover, takes 
away all practical difficulty from the operation. The straining to 
which the defibriuated blood is subjected entirely prevents the possi- 
bility of even the most minute particle of fibrin being contained in the 

1 Guy's Hospital Reports, 1869, vol. xiv., 3d series, p. 1. 

2 Panurn: Virchow's Arch., vol. xxvii. 



THE TRANSFUSION OF BLOOD. 569 

injected fluid ; the risk from embolism is, therefore, less than in anv 
of the other processes already referred to. My own experience of this 
plan is limited to three cases, but in two it answered so well that I can 
conceive no reasonable objection to it. I should be inclined to say that 
transfusion, thus performed, is amongst the simplest of surgical^er- 
ations — an opinion which the experience of McDonnell and others 
fully confirms. 

Transfusion of Milk. — Recently the intra-venous injection of 
freshly -drawn warm milk has been recommended as a substitute for 
blood, chiefly in America. It was first used by Dr. Hoclder, of 
Toronto, but has been introduced and strongly advocated by Thomas, 
of New York, who has used it twice after ovariotomy. Brown-Sequard, 
in experimenting on the lower animals, found that it answered as well 
as either fresh or defibrinated blood, and about half an hour after the 
injection no trace of the milk corpuscles could be found in the blood. 
Schafer, however, found that the action of milk on the blood corpuscles 
was highly deleterious, and that it introduces the germs of septic 
organisms likely to produce very serious results. He, therefore, pro- 
nounces strongly against its use. 

Injection of Saline Solutions. — Dr. William Hunter 1 has recently 
published a series of valuable observations on the subject of transfusion. 
His conclusions are that its principal effects are those of stimulation, 
and that, for all practical purposes, in cases of severe hemorrhage, the 
injection of a saline solution is quite as efficacious, and much simpler. 
For this purpose all that is required is a glass canula, such as Schafer's, 
a piece of India-rubber tubing, and a syringe, all of which should be, 
of course, carefully asepticized. The fluid to be injected is very readilv 
manufactured by dissolving a teaspoonful of common salt in a pint of 
water at a temperature of 100°. It has been suggested 2 that the injec- 
tion of the same solution into the muscular tissues will answer equally 
Avell. For this purpose the needle of an aspirator is attached by a 
piece of India-rubber tubing to an ordinary glass funnel. The needle 
is inserted into the gluteal region or loins, and the saline infusion 
poured into the funnel. After it has entered the tissues it is diffused 
by massage. Both these methods have the great advantage of sim- 
plicity, and, if further experience proves them to be as efficacious as 
they are said to be, will prove valuable in many cases in which the 
transfusion of blood cannot be employed. 

Statistical Results. — The number of cases of transfusion are per- 
haps not sufficient to admit of completely reliable conclusions. It is 
certain, however, that transfusion has often been the means of rescuing 
the patient when apparently at the point of death, and after all other 
means of treatment had failed. Professor Martin records 57 cases, in 
43 of which transfusion was completely successful, and in 7 tem- 
porarily so ; while in the remaining 7 no reaction took place. Dr. 
Higginson, of Liverpool, has had 15 cases, 10 of which were suc- 
cessful. Figures such as these are encouraging, and they are sufficient 
to prove that the operation is one which at least offers a fair hope of 

i Brit. Med. Journ., vol. ii., 1889. 

2 Munchmeyer : Arch, fiir Gynak., Bd. xxxiv. Hft. 3. 



570 OBSTETRIC OPERATIONS. 

success, and which no obstetrician would be justified in neglecting, 
when the patient is sinking from the exhaustion of profuse hemor- 
rhage, It is to be hoped also that further experience may prove it to 
be of value in other cases in which its use has been suggested, but not, 
as yet, put to the test of experiment. 

Possible Dangers of the Operation. — The possible risks of the 
operation would seem to be the danger of injecting minute particles of 
fibrin which form emboli ; of bubbles of air ; or of overwhelming the 
action of the heart by injecting too rapidly, or in too great quantity. 
These may be, to a great extent, prevented by careful attention to the 
proper performance of the operation, and it does not clearly appear, 
from the recorded cases, that they have ever proved fatal. We must 
also bear in mind that transfusion is seldom or never likely to be 
attempted until the patient is in a state which would otherwise almost 
certainly preclude the hope of recovery, and in which, therefore, much 
more hazardous proceedings would be fully justified. 

Cases Suitable for Transfusion. — The cases suitable for trans- 
fusion are those in which the patient is reduced to an extreme state of 
exhaustion from hemorrhage during or after labor or miscarriage, 
whether by the repeated losses of placenta previa, or the more sudden 
and profuse flooding of post-partum hemorrhage. The operation will 
not be contemplated until other and simpler means have been tried and 
failed, or until the symptoms indicate that life is on the verge of ex- 
tinction. If the patient should be deadly pale and cold, with no pulse 
at the wrist, or one that is scarcely perceptible ; if she be unable to 
swallow, or vomits incessantly ; if she lie in an unconscious state ; if 
jactitation, or convulsions, or repeated faintings should occur ; if the 
respiration be laborious, or very rapid and sighing ; if the pupils do 
not act under the influence of light, it is evident that she is in a condi- 
tion of extreme danger, and it is under such circumstances that trans- 
fusion, performed sufficiently soon, offers a fair prospect of success. It 
does not necessarily follow because one or other of these symptoms is 
present that there is no chance of recovery under ordinary treatment, 
and, indeed, it is within the experience of all that patients have rallied 
under apparently the most hopeless conditions. But when several of 
them occur together, the prospect of recovery is much diminished, and 
transfusion would then be fully justified, especially as there is no reason 
to think that a fatal result has ever been directly traced to its employ- 
ment. Indeed, like most other obstetric operations, it is more likely 
to be postponed until too late to be of good service, than to be employed 
too early ; and in some of the cases reported as unsuccessful it was 
not performed until respiration had ceased and death had actually 
taken place. It has sometimes been said that transfusion should never 
be employed if the uterus be not firmly contracted, so as to prevent the 
injected blood again escaping through the uterine sinuses. The cases 
in which this is likely to occur are few ; and if one were met with, the 
escape of blood could be prevented by the injection into the uterus of 
the perchloride of iron. 

Description of the Operation. — In describing the operation I 
shall limit myself to an account of Aveling's and Schafer's method of 



THE TRANSFUSION OF BLOOD. 



571 



immediate transfusion, and to that of injecting defibrinated blood. I 
consider myself justified in omitting any account of the numerous in- 
struments which have been invented for the purpose of injecting pure 
blood, since I believe the practical difficulties arc too great ever to 
render this form of operation serviceable. The great objection to 
most of them is their cost and complexity ; and as long as any special 
apparatus is considered essential, the full benefits to be derived from 
transfusion are not likely to be realized. The necessity for employing 
it arises suddenly ; it may be in a locality in which it is impossible to 
procure a special instrument ; and it would be well if it were under- 
stood that transfusion may be safely and effectually performed by the 
simplest means. In many of the successful eases an ordinary syringe 
was used; in one, in the absence of other instruments, a child's tov 
syringe was employed. I have myself performed it with a simple 
syringe purchased at the nearest chemist's shop, when a special trans- 
fusion apparatus failed to act satisfactorily. 



Fig. 204. 




Method of transfusion by Aveling's apparatus. 



In immediate transfusion (Fig. 204), the donor is seated close to 
the patient, and the veins in the arms of each having been opened, 
the silver can u la at either end of the instrument is introduced into 
them (a b). The tube between the bulb and the donor is now pinched 
(d), so as to form a vacuum, and the bulb becomes filled with blood 
from the donor. The finger is now removed so as to compress the 
distal tube (d'), and the bulb being compressed (c), its contents are 
injected into the patient's vein. The bulb is calculated to hold 
about two drachms, so that the amount injected can be estimated by 
the number of times it is emptied. The risk of injecting air is pre- 
vented by filling the syringe with water which is injected before the 
blood. 



Schafer's Directions for Immediate Transfusion. 

Direct Venous Transfusion. — " Procure two glass canulas of appro- 
priate size and shape (see Fig. 205), and a piece of black India-rubber 



572 OBSTETRIC OPERATIONS. 

tubing, seven inches long, and not less than a quarter of an inch bore, 
fitted to the canulas. This apparatus could always be improvised. 

" Place the transfusion-tube in a basin of hot water containing a 
little carbonate of soda. Put a tape around the arm of the patient 
just below the place where the vein is to be opened, and another just 
above. Expose the vein by an incision through the skin, which should 
be made transversely if the position of the vein cannot be made out 
through the skin. Clear a small piece of the vein with forceps, and 
slip a pointed piece of card underneath it. By a snip with scissors 
make an oblique opening into the vein, and partly insert a small 
blunt instrument (such as a wool-needle) so that the aperture is not 
lost. Remove the upper tape. Xext prepare the vein of the giver. 
To do this put tapes around the arm just below and above the place 
where the vein is to be opened. Expose the vein by a longitudinal 
incision through the skin. Clear a small piece of the 
vessel with forceps and pass a thread ligature under- 
neath. A slip of card may also be placed under this 
vein. Make a snip into the vein just above the liga- 
ture, and then, taking the transfusion-tube out of the 
soda solution, slip one of the canulas into the vein 
of the giver, and tie it in Avith a simple knot, which 
can be readily untied. Let the giver go to the bed- 
side and place his arm alongside that of the patient. 
Hold the end of the India-rubber tube with the 
second canula up a little, and release the lower tape 
on the arm of the blood-giver. As soon as blood 
flows out of the second canula pinch the India-rubber 
tube close to the canula, so as to stop the flow, and, 
removing the wool-needle, slip the end of the canula 
into the vein of the patient, hold it there, and allow the blood to pass 
freely along the tube. Three minutes will generally be long enough 
for the flow, which can be stopped by compressing the vein of the 
giver below the canula. Both canulas may now be withdrawn and 
the ligature removed from the vein of the giver, the cut veins being 
dealt with in the usual way. Of course, the other tape on the arm of 
the donor must be removed as soon as the transfusion is over. 

•• Instead of using the transfusion-tube empty, it may be filled with 
soda solution, to the exclusion of air. It is necessary to have one or 
two spring clips on the tube to prevent the escape of the solution. 
This is a much better plan than the other, for the blood need not be 
allowed to flow into the tube until the second canula is inserted, and 
then, by opening the clips, it may drive the soda solution before it 
into the vein. The small quantity of carbonate of soda solution neces- 
sary to fill the simple tube will do the patient no harm." 

Injection of Deflbrinated Blood. — For injecting defibrinated blood 
various contrivances have been used. McDonnell's instrument is 
a simple cylinder with a nozzle attached, from which the blood is 
propelled by gravitation. When the propulsive power is insufficient, 
increased pressure is applied by breathing forcibly into the open end 
of the receiver. De Belina's instrument is on the same principle, 




the tra: b of blo 

only atmospheric press - - I by a contrivance similar t<> 

Richardson's spray-pr ttached 1 1. The: 5 simple, 

but there is s«»nie doubt gravitation instrument being sufficiently 

powerful, and it certainly failed in my hands. I have had the valves 

ling's instrument, so that it works I -- 

the bulb, like an ordinary Higginson's syringe. This, with a single 
silver eanula at nd for introduction into the veil:. 

fed and u ave transfusion apparatus, taking up little space. If 

it be not at hand, any small syringe with a line nozzle may be ' - 

ration is defibrination of the bloody which 
should, if possible, red in an apartment adjoining the patient'-. 

The blood should be taken from the arm of a ~tr«;»ng and healthy 
man. The quality cannot be unimportant, and in s :>rded 

- - the failure of the operation has been attributed to the fact of the 
donor having been a weakly female. The supply from a woman 
might also pi >ve insufficient : and, although it has been shown that 
blood from two or moi re as maybe use I with safety, yet such a 
change necessarily causes delay, and should, if possible, be av 

in having a opened, eight or ten ounces of blood are with- 
drawn and received into some perfectly clean vessel, such as a finger- 
bowL As it flows it should be briskly agitated with a clean silver 
fork or a glass rod. and very shortly strings of fibrin begin to form. 
It is now strained through a piece of fine muslin, previously dipped 
in hot water, into a second vessel which is floating in water at a tem- 
perature of about 105°. By this straining, the fibrin and all air- 
bubbles resulting from the agitation are removed : if in no excessiv 
hurry, straining may be done a - ad time. If the vessel be kept 
floating in warm water, the blood is prevented front getting cool, and 
we can now proceed to prepare the arm of the patient for injection. 

This is the most delicate and difficult part of the operation, since 
the veins are generally collapsed and empty, and by no means easy to 
find. The best way of exposing them is that practised by McDonnell, 
who pinches up a fold of the skin at the bend of the elbow, and trans- 
it with a fine tenotomy kni: scalpel, sc making a gaping 
wound in the integument, at the bottom of which they are seen lying. 
A probe should now be passed underneath the vein selected for 
i ng - 3 to avoid the chance of its being lost at any subsequent st _ 
of the operation. This is a point of some inr. :: . and from the 
neglect of this precaution I have been obliged to < -pen another vein 
than that originally fixed on. A small portion of the vein being 
raised with the : pe a nick is made into it for the eanula. 

Injection of the Blood. — The prepared blood is now brought t 
bedside, and the apparatus having been previously filled with bl 
avoid the risk of injecting any bub: I - ir, the eanula is inserted into 
the opening made in the vein, and transfusion commenced. It should be 
constantlv borne in mind that this part of the operation should 1 
ducted with ti. _ best ration, the blood into ryslowl 

the effect on the patient carefully watched. The injection may be pro- 

•1 with until some perceptible effect is } I, which will _ 

ally be a return of the pulsation, first at the heart and subsequently at 



574 OBSTETRIC OPERATION'S. 

the wrist, an increase in the temperature of the body, greater depth and 
frequency of the respirations, and a general appearance of returning 
animation about the countenance. Sometimes the arms have been 
thrown about, or spasmodic twitchings of the face have taken place. 
The quantity of blood required to produce these effects varies greatly, 
but in the majority of cases has been very small. Occasionally two 
ounces have proved sufficient, and the average may be taken as ranging 
between four and six ; although in a few cases between ten and twenty 
have been used. The practical rule is to proceed very slowly with the 
injection until some perceptible result is observed. Should embarrassed 
or frequent respiration supervene, we may suspect that we have been 
injecting either too great a quantity of blood, or with too much force 
and rapidity, and should desist until the suspicious symptoms pass 
away. It may happen that the effects of the transfusion have been 
highly satisfactory, but that in the course of time there is evidence of 
returning syncope. This may possibly be prevented by the adminis- 
tration of stimulants, but if these fail there is no reason why a fresh 
supply of blood should not again be injected, but this should be done 
before the effects of the first transfusion have entirely passed away. 

Secondary Effects of Transfusion. — The subsequent effects in 
successful cases of transfusion merit careful study. In some few cases 
death is said to have happened within a few weeks, with symptoms 
resembling pyaemia. Too little is known on this point, however . to 
justify any positive conclusions with regard to it. 

[Transfusion with defibrinated blood was, I believe, first tried in 
America by Dr. Joshua G. Allen, of Philadelphia, on December 30, 
1868, on a woman who suffered from the effects of repeated attacks of 
uterine hemorrhage. Six fluidonnces were injected, and the patient 
recovered a reasonable degree of health. In 1869, Dr. Allen repeated 
the operation four times, in two of the cases being associated with Dr. 
Thomas G. Morton at the Pennsylvania Hospital, and using a double 
vessel for keeping the blood warm, consisting of a conical cup for hold- 
ing; the blood and a lower vessel for containing; warm water, the two 

. . . . 

being made in one and the temperature ascertained by an outside ther- 
mometer. Dr. Morton repeated the experiment on two other patients 
in 1870 and 1874, the second, a girl of eleven, being operated on twice, 
at intervals of six weeks, for bleeding from the nose and bladder, the 
effect of purpura ; she entirely recovered. Dr. M. used a set of instru- 
ments specially designed for the work, and shown in illustration in the 
Amer. Journ. of the Med. Sciences, July, 1 8 74, p. 1 1 2. Between 1874 and 
1886 he repeated the operation on several hospital and private patients. 

Intra-venous saline injections are far more readily used, are safer, 
and are believed from the tests that have been made to be quite as effi- 
cacious as blood. What has been called artificial serum consists of 20 
grammes of sulphate of soda and 10 grammes of chloride of sodium in 2 
litres of water. The solution should be injected into a large vein slowly 
and in large quantity, as much as a pint or more at a time, and repeated 
at intervals ; the fluid should be blood-warm. Another formula consists 
of pure common salt 1J fluidrachms, liquor potassae 1 minim, and 
pure carbonate of potash 45 grains in two quarts of water. — Ed.] 



PART V. 

THE PUERPERAL STATE. 
CHAPTEE I. 

THE PUERPERAL STATE AND ITS MANAGEMENT. 

Importance of Studying- the Puerperal State. — The key to the 
management of women after labor, and to the proper understanding of 
the many important diseases which may then occur, is to be found in 
a study of the phenomena following delivery, and of the changes going 
on in the mother's system during the puerperal period. Xo doubt 
natural labor is a physiological and healthy function, and during 
recovery from its effects disease should not occur. It must not be for- 
gotten, however, that none of our patients are under physiologically 
healthy conditions. The surroundings of the lying-in woman, the 
effects of civilization, of errors of diet, of defective cleanliness, of 
exposure to contagion, and of a hundred other conditions which it is 
impossible to appreciate, have most important influences on the results 
of childbirth. Hence it follows that labor, even under the most favor- 
able conditions, is attended with considerable risk 

The Mortality of Childbirth. — It is not easy to say with accuracy 
what is the precise mortality accompanying childbirth in ordinary 
domestic practice, since the returns derived from the reports of the 
Registrar-General, or from private sources, are manifestly open to seri- 
ous error. The nearest approach to a reliable estimate is that made 
by the late Dr. Matthews Duncan, 1 who calculated, from figures derived 
from various sources, that no fewer than 1 out of every 120 women, 
delivered at or near the full time, died within four weeks of childbirth. 
This indicates a mortality far above that which has been generally 
believed to accompany childbearing under favorable circumstances. 
It, however, closely approximates to a similar estimate made by Mc- 
Clintock, 2 who calculated the mortality in England and Wales as 1 in 
12b' ; and in the upper and middle classes alone, where the conditions 
may naturally be supposed to be more favorable, at 1 in 146 ; more 
recently he had come to the conclusion from his own increased experi- 
ence, and the published results of the practice of others, that 1 in 100 
would more correctly represent the rate of puerperal mortality. 3 In 

i The " Mortality of Childbed.'' Edin. Med. Journ., vol. lSfi'j-70. p. 39'J. 
2 Dublin Quarterly Journ. of Med. Science, istjy. vol. xlviii. p. 25(3. 
s Brit. Med. Journ., 1S7S, vol. ii. p. 215. 

(575) 



576 THE PUERPERAL STATE. 

these calculations there are some obvious sources of error, since they 
include deaths from all causes within four weeks of delivery, some of 
which must have been independent of the puerperal state. 

But it is not the deaths alone which should be considered. All 
practitioners know how large a number of their patients suffer from 
morbid states which may be directly traced to the effects of childbear- 
ing. It is impossible to arrive at any statistical conclusion on this 
point, but it must have a very sensible and important influence on the 
health of childbearing women. 

Alterations in the Blood after Delivery. — The state of the blood 
during pregnancy, already referred to (p. 145), has an important bear- 
ing on the puerperal state. There is hyperinosis, which is largely 
increased by the changes going on immediately after the birth of the 
child ; for then the large supply of blood which has been going to the 
uterus is suddenly stopped, and the system must also get rid of a 
quantity of effete matter thrown into the circulation, in consequence of 
the degenerative changes occurring in the muscular fibres of the uterus. 
Hence all the depurative channels by which this can be eliminated 
are called on to act with great energy. If, in addition, the peculiar 
condition of the generative tract be borne in mind — viz., the large open 
vessels on its inner surface, the partially bared inner surface of the 
uterus, and the channels for absorption existing in consequence of 
slight lacerations in the cervix or vagina — it is not a matter of surprise 
that septic diseases should be so common. 

It will be well to consider successively the various changes going 
on after delivery, and then we shall be in a better position for study- 
ing the rational management of the puerperal state. 

Some degree of nervous shock or exhaustion is observable after 
most labors. In many cases it is entirely absent ; in others it is well 
marked. Its amount is in proportion to the severity of the labor 
and the susceptibility of the patient ; and it is, therefore, most likely 
to be excessive in women who have suffered greatly from pain, who 
have undergone much muscular exertion, or who have been weakened 
from undue loss of blood. It is evidenced by a feeling of exhaustion 
and fatigue, and not uncommonly there is some shivering, which soon 
passes off, and is generally followed by refreshing sleep. The extreme 
nervous susceptibility continues for a considerable time after delivery, 
and indicates the necessity of keeping the lying-in patient as free from 
all sources of excitement as possible. 

Immediately after delivery the pulse falls, and the importance of 
this as indicating a favorable state of the patient has already been 
alluded to. The condition of the pulse has been carefully studied by 
Blot, 1 who has shown that this diminution, which he believes to be 
connected with a diminished tension in the arteries due to the sudden 
arrest of the uterine circulation, continues, in a large proportion of 
cases, for a considerable number of days after delivery; and, as a 
matter of clinical import, as long as it does, the patient may be con- 
sidered to be in a favorable state. In many instances the slowness of 

i Arch. gen. de Med., 1864. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 577 

the pulse is remarkable, often Binking to fifty or even forty beats per 
minute. Any increase above the normal rate, especially [f at all con- 
tinuous, should always be carefully noted and looked on with suspi- 
cion. In connection with this subject, however, it must be remembered 
that in puerperal women the most trivial circumstances may cause 
a. sudden rise of the pulse. This must he familar to every practical 
obstetrician, who has constant opportunities of observing this effect 
after any transient excitement or fatigue. In lying-in hospitals it has 
generally been observed that the occurrence of any particularly bad 
case will send up the pulse of all the other oatients who may have 
heard of it. 

Temperature in the Puerperal State. — The temperature in the 
lying-in state affords much valuable information. During and for a 
short time after labor there is a slight elevation. It soon falls to, or 
even somewhat below, the normal level. Squire found that the fall 
occurred Avithin twenty-four hours, sometimes within twelve hours 
after the termination of labor. 1 For a few days there is often a slight 
increase of temperature, especially toward the evening, which is prob- 
ably caused by the rapid oxidation of tissue in connection with the 
involution of the uterus. In about forty-eight hours there is a rise 
connected with the establishment of lactation, amounting to one or two 
degrees over the normal level ; but this again subsides as soon as the 
milk is freely secreted. Crede has also shown 2 that rapid, but transient, 
rises of temperature may occur at any period, connected with trivial 
causes, such as constipation, errors of diet, or mental disturbances. 
But if there be any rise of temperature which is at all continuous, 
especially to over 100° Fahr., and associated with rapidity of the 
pulse, there is reason to fear the existence of some complication. 

The Secretions and Excretions. — The various secretions and ex- 
cretions are carried on with increased activity after labor. The skin 
especially acts freely, the patient often sweating profusely. There is 
also an abundant secretion of urine, but not uncommonly a difficulty 
of voiding it, either on account of temporary paralysis of the neck of 
the bladder, resulting from the pressure to which it has been subjected, 
or from swelling and occlusion of the urethra. For the same reason 
the rectum is sluggish for a time, and constipation is not infrequent. 
The appetite is generally indifferent, and the patient is often thirsty. 

Generally in about forty-eight hours the secretion of milk becomes 
established, and this is occasionally accompanied by a certain amount 
of constitutional irritation. The breasts often become turgid, hot, and 
painful. There may or may not be some general disturbance, quick- 
ening of pulse, elevation of temperature, possibly slight shivering and 
a general sense of oppression, which are quickly relieved as the milk 
is formed and the breasts emptied by suckling. Squire says that the 
most constant phenomenon connected with the temperature is a slight 
elevation as the milk is secreted, rapidly falling when lactation is 
established. Barker noted elevation, either of temperature or pulse, 
in only four out of fifty-two cases that were carefully Matched. There 

1 " Puerperal Temperatures." Obstetrical Transactions, 1868, vol. ix. p. 129. 

2 Monats. f. Geburt., 1868, Bd. xxxii. S. 453. 

37 



578 THE PUERPERAL STATE. 

can be little doubt that the importance of the so-called " milk fever " 
has been immensely exaggerated, and its existence, as a normal accom- 
paniment of the puerperal state, is more than doubtful. It is certain, 
however, that in a small minority of cases there is an appreciable 
amount of disturbance about the time that the milk is formed. Out 
of 423 cases, Macan 1 found that in 114, or about 27 per cent., there 
was no rise of temperature ; in 226 the temperature did rise to 100° 
aud over, and of these in 32, or a little over 7 cent., the only ascer- 
tainable cause was a painful or distended condition of the breast. 
Many modern writers, such as Winckel, Griinewaldt, and D'Espine, 
entirely deny the connection of this disturbance with lactation, and 
refer it to a slight and transient septicaemia. Graily Hewitt remarks 
that it is most commonly met with when the patient is kept low and 
on deficient diet after delivery, especially when the system is below 
par from hemorrhage or any other cause. This observation will, no 
doubt, account for the comparative rarity of febrile disturbance in 
connection with lactation in these days, in which the starving of puer- 
peral patients is not considered necessary. It is certain that anything 
deserving the name of milk fever is now altogether exceptional, and 
such feverishness as exists is generally quite transient. It is also a 
fact that it is most apt to occur in delicate and weakly women, espe- 
cially in those Avho do not, or are unable to, nurse. There does not, 
however, seem to be any sufficient reason for referring it, even when 
tolerably w^ell marked, to septicaemia. The relief which attends the 
emptying of the breasts seems sufficient to prove its connection with 
lactation, and the discomfort which is necessarily associated with the 
swollen and turgid mammae is, of itself, quite sufficient to explain it. 

In the urine of women during lactation an appreciable amount of 
sugar may readily be detected. The amount varies according to the 
condition of the breasts. It increases when they are turgid and con- 
gested, and is, therefore, most abundant in women in whom the 
breasts are not emptied, as when the child is dead, or when lactation is 
not attempted. 

Contraction of the Uterus after Delivery. — Immediately after 
delivery the uterus contracts firmly, and can be felt at the lower part 
of the abdomen as a hard, firm mass, about the size of a cricket-ball. 
(Plate V.) After a time it again relaxes somewhat, and alternate 
relaxations and contractions go on at intervals for a considerable time 
after the expulsion of the placenta. The more complete and perma- 
nent the contraction, the greater the safety and comfort of the patient ; 
for w r hen the organ remains in a state of partial relaxation, coagula 
are apt to be retained in its cavity, while, for the same reason, air enters 
more readily into it. Hence decomposition is favored, and the chances 
of septic absorption are much increased ; while even when this does 
not occur, the muscular fibres are excited to contract, and severe after- 
pains are produced. 

After the first few days the diminution in the size of the uterus pro- 
gresses with great rapidity. By about the sixth day it is so much 

1 Dublin Quarterly Journ. of Med. Science, 1878, vol. lxv. p. 435. 



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THE PUERPERAL STATE AND ITS MANAGEMENT. 579 

lessened as to project doI more than one and a half or two inches above 
the pelvic brim, while by the eleventh day it is no Longer to be made 
out by abdominal palpation. Its increased size is, however, still ap- 
parent per vaginam, and should occasion arise for making internal 

examination, the mass of the lower Begmenl of the uterus, with its 
flabby and patulous cervix, can be felt for some weeks after delivery. 

This may sometimes he of practical value in cases in which it is neces- 
sary to ascertain the fact of recent delivery, and under these circum- 
stances, as pointed out by Simpson, the uterine Bound would also enable 
us to prove that the cavity of the uterus is considerably elongated. 
Indeed, the normal condition of the uterus and cervix is not regained 
until six weeks or two months after labor. These observations are 
corroborated bv investigations on the weight of the organ at different 
periods after labor. Thus Heschl 1 has shown that the uterus, imme- 
diately after delivery, weighs about twenty-two to twenty-four ounces; 
within a week, it weighs nineteen to twenty-one ounces ; and at the 
end of the second week, ten to eleven ounces only. At the end of the 
third week, it weighs five to seven ounces ; but it is not until the end 
of the second month that it reaches its normal weight. Hence it 
appears that the most rapid diminution occurs during the second week 
after delivery. 

Fatty Transformation of the Muscular Fibres. — The mode in 
which this diminution in size is effected is by the transformation of 
the muscular fibres into molecular fat, which is absorbed into the 
maternal vascular system, which, therefore, becomes loaded with a 
large amount of effete material. Heschl believed that the entire mass 
of the enlarged uterine muscles is removed, and replaced by newly- 
formed fibres, which commence to be developed about the fourth week 
after delivery, the change being complete about the end of the second 
month. Luschka and Robin 2 contend that this entire change in the 
structure of the fibres does not occur, but that their diminution in size 
is effected by granular degeneration and subsequent absorption of the 
existing muscle cells, by means of which they become gradually 
reduced to their natural size. This view has been more recently main- 
tained by Sanger. Generally speaking, involution goes on without 
interruption. It is, however, apt to be interfered with by a variety of 
causes, such as premature exertion, intercurrent disease, and very prob- 
ably by neglect of lactation. Hence the uterus often remains large 
and bulky, and the foundation for many subsequent uterine ailments 
is laid. 

Changes in the Uterine Vessels. — AVilliams 3 has drawn attention 
to changes occurring in the vessels of the uterus, some of which seem 
to be permanent, and may, should further observations corroborate his 
investigations, prove of value in enabling us to ascertain whether a 
uterus is nulliparous or the reverse ; a question which may be of 
medico-legal importance. After pregnancy he found all the vessels 
enlarged in calibre. The coats of the arteries are thickened and 

1 Researches on the Conduct of the Human Uterus after Delivery. 

2 "The Involution of the Muscular Tissue of the Puerperal Uterus," Annals of Gvnecology, 
Boston, July, 1888. 

3 " Changes in the Uterus resulting from Gestation," Obst. Trans., vol. xx. 



580 



THE PUERPERAL STATE 



hypertrophied, and this he has observed even in the uteri of aged 
women who have not borne children for many years. The venous 
sinuses, especially at the placental site, have their walls greatly 
thickened and convoluted, and contain in their centre a small clot of 
blood (Fig. 206). This thickening attains its greatest dimensions in 
the third month after gestation, but traces of it may be detected as late 
as ten or twelve weeks after labor. 

Changes in the Uterine Mucous Membrane. — The changes going 
on in the lining membrane of the uterus immediately after delivery are 
of great importance in leading to a knowledge of the puerperal state, 
and have already been discussed when describing the decidua (p. 106). 

Fig. 206. 




Section of a uterine sinus from the placental site nine weeks after delivery. 
(After Williams.) 

Its cavity is covered with a reddish-gray film, formed of blood and 
fibrin. The open mouths of the uterine sinuses are still visible, more 
especially over the site of the placenta, and thrombi may be seen pro- 
jecting from them. The placental site can be distinctly made out in 
the form of an irregularly oval patch, where the lining membrane is 
thicker than elsewhere. (See Plate V.) 

Contraction of the Vagina, etc. — The vagina soon contracts, and 
by the time the puerperal month is over it has returned to its normal 
dimensions, but after childbearing it always remains more lax and 
less rugose than in nulliparae. The vulva, at first very lax and much 
distended, soon regains its former state. The abdominal parietes re- 
main loose and flabby for a considerable time, and the white streaks, 
produced by the distention of the cutis very generally become per- 
manent. In some women, especially when proper support by band- 



THE PUERPERAL STATE AND ITS MANAGEMENT. 581 

aging has aol been given, the abdomen remains permanently Loose and 
pendulous. 

The Lochial Discharge. — From the time of delivery up to about 
three weeks afterward a discharge escapes from the interior of the 
uterus, known as the lochia. At firsi this consists almost entirely of 
pure blood, mixed with a variable amount of coagula. If efficient 
uterine contraction has not been secured after the expulsion of the 
placenta, coagula of considerable size are frequently expelled with the 
lochia for one or two days after delivery. In three or four days the 
distinctly bloody character of the lochia is altered. They have a red- 
dish watery appearance, and are known as the lochia rubra or cruenta. 
According to the researches of \Yertheimer, 1 they are at this time 
composed chiefly of blood corpuscles, mixed with epithelium scales, 
mucous corpuscles, and the debris of the decidua. The change in the 
appearance of the discharge progresses gradually, and about the seventh 
or eighth day it has no longer a red color, but is a pale greenish fluid, 
with a peculiar sickening and disagreeable odor, and is familiarly 
described as the " green waters." It now contains a small quantity 
of blood corpuscles, which lessen in amount from day to day, but a 
considerable number of pus corpuscles, which remain the principal 
constituent of the discharge until it ceases. Besides these, epithelial 
scales, fatty granules, and crystals of cholesterin are observed. Vari- 
ous micro-organisms are found in the discharge, especially in the lower 
part of the vagina, such as the trichomonas vaginalis, streptococci, rod 
bacteria, and others, and they increase in numbers toward the end of 
the week after delivery. The conditions existing in the vagina greatly 
favor their growth, and hence the special importance of strict attention 
to cleanliness and antiseptic precautions during convalescence. 

The amount of the lochia varies much, and in some women it 
is habitually more abundant than in others. Under ordinary circum- 
stances it is very scanty after the first fortnight, but occasionally it 
continues somewhat abundant for a month or more, without any bad 
results. It is apt again to become of a red color, and to increase in quan- 
tity, in consequence of any slight excitement or disturbance. If this 
red discharge continues for anv undue length of time, there is reason 
to suspect some abnormality, and it may not imfrequently be traced to 
slight lacerations about the cervix, which have not healed properly. 
This result may also follow premature exertion, interfering with the 
proper involution of the uterus ; and the patient should certainly not be 
allowed to move about as long as much colored discharge is going on. 

Occasionally the lochia have an intensely fetid odor. This must 
always give rise to some anxiety, since it often indicates the retention 
and putrefaction of coagula, and involves the risk of septic absorption. 
It is not very rare, however, to observe a most disagreeable odor per- 
sist in the lochia without any bad results. The fetor always deserves 
careful attention, and an endeavor should be made to obviate it by 
directing the nurse to syringe out the vagina freely night and morning 
with creolin and water; while, if it be associated with quickened 

i Virchow's Arch.. 1861. 



582 THE PUERPERAL STATE. 

pulse and elevated temperature, other measures, to be subsequently 
described, will be necessary. 

The after-pains, which many childbearing women dread even more 
than the ' labor pains, are irregular contractions occurring for a vary- 
ing time after delivery, and resulting from the efforts of the uterus to 
expel coagala which have formed in its interior. If, therefore, special 
care be taken to secure complete and permanent contraction after labor, 
they rarely occur, or to a very slight extent. Their dependence on 
uterine inertia is evidenced by the common observation that they are 
seldom met with in priraiparse, in whom uterine contraction may be 
supposed to be more efficient, and are more frequent in women who 
have borne many children. They are a preventable complication, and 
one which need not give rise to any anxiety ■ they are, indeed, rather 
salutary than the reverse ; for, if coagula be retained in utero, the 
sooner they are expelled the better. The after-pains generally begin 
a few hours after delivery, and continue in bad cases for three or four 
days, but seldom longer. They are generally increased when the 
mammae are irritated by suction. When at their height they are often 
relieved by the expulsion of the coagula. In some severe cases they 
are apparently neuralgic in character, and do not seem to depend on 
the retention of coagula. They may be readilv distinguished from 
pains due to more serious causes, by feeling the enlarged uterus harden 
under their influence, by the uterus not being tender on pressure, and 
by the absence of any constitutional symptoms. 

The management of women after childbirth has varied much at 
different times, according to fashion or theory. The dread of inflam- 
mation long influenced the professional mind and caused the adoption 
of a strictly antiphlogistic diet, which led to a tardy convalescence. 
The recognition of the essentially physiological character of labor has 
resulted in more sound views, with manifest advantage to our patients. 
The main facts to bear in mind with regard to the puerperal woman 
are : her nervous susceptibility, which necessitates quiet and absence of 
all excitement ; the importance of favoring involution by prolonged 
rest; and the risk of septicaemia, which calls for perfect cleanliness 
and attention to hygienic precautions. 

As soon as we are satisfied that the uterus is perfectly contracted 
and that all risk of hemorrhage is over, the patient should be left to 
sleep. Many practitioners administer an opiate ; but as a matter of 
routine this is certainly not good practice, since it checks the contrac- 
tions of the uterus and often produces unpleasant effects. Still, if the 
labor have been long and tedious, and the patient be much exhausted, 
fifteen or twenty drops of Battley's solution may be administered with 
advantage. 

Within a few hours the patient should be seen, and at the first visit 
particular attention should be paid to the state of the pulse, the uterus, 
and the bladder. The pulse during the whole period of convalescence 
should be carefully watched, and, if it be at all elevated, the tempera- 
ture should at once be taken. If the pulse and temperature remain 
normal, we may be satisfied that things are going on well ; but if the 
one be quickened and the other elevated, some disturbance or compli- 



THE PUERPERAL STATE AND ITS MANAGEMENT. 583 

cation may be apprehended. The abdomen should be felt, to see that 
the uterus is not unduly distended and that there is no tenderness. 
Alter the first day or two this is no longer necessary. 

Treatment of Retention of Urine. — Sometimes the patient cannot 
at first void the urine, and the application of a hot sponge over the 
pubes may enable her to do so. If the retention of urine be due to 
temporary paralysis of the bladder, three or four 20-minim doses of 
the liquid extract of ergot, at intervals of half an hour, may prove 
successful. Many hours should not be allowed to elapse without 
relieving the patient by the catheter, since prolonged retention is only 
likely to make matters worse. In many cases the use of the catheter 
may be avoided by propping up the patient in the sitting posture, in 
which she is often able to micturate when she cannot do so lying, and 
this plan has the further advantage of allowing the lochia to drain 
away from the vagina. It may be necessary, subsequently, to empty 
the bladder night and morning, until the patient regain her power 
over it, or until the swelling of the urethra subsides, and this will 
generally be the case in a few days. The utmost care should be taken 
to keep the catheter aseptic, and it should lie in a basin of 1 : 1000 
sublimate solution, otherwise its frequent use might lead to cystitis. 
Occasionally the bladder becomes largely distended, and is relieved to 
some degree by dribbling of urine from the urethra. Such a state of 
things may deceive the patient and nurse, and may produce serious 
consequences. Attention to the condition of the abdomen will prevent 
the practitioner from being deceived, for in addition to some constitu- 
tional disturbance, a large, tender, and fluctuating swelling will be found 
in the hypogastric region distinct from the uterus, which it displaces 
to one or other side. The catheter will at once prove that this is pro- 
duced by distention of the bladder. 

Treatment of Severe After-pains. — If the after-pains be very 
severe, an opiate may be administered, or, if the lochia be not over- 
abundant, a linseed-meal poultice, sprinkled with laudanum, or with 
the chloroform and belladonna liniment, may be applied. If proper 
care have been taken to induce uterine contraction, they will seldom 
be sufficiently severe to require treatment. In America quinine, in 
doses of 10 grains twice daily, has been strongly recommended, espe- 
cially when opiates fail and when the pains are neuralgic in character, 
and I have found this remedy answer extremely well. The quinine is 
best given in solution with 10 or 15 minims of hydrobromic acid, 
which materially lessens the unpleasant head symptoms often accom- 
panying the administration of such large doses. The inhalation of the 
nitrite of amyl in severe cases is said to be very efficacious. 1 

Diet and Regimen. — The diet of the puerperal patient claims 
careful attention, the more so as old prejudices in this respect are as 
yet far from exploded, and it is by no means rare to find mothers and 
nurses who still cling tenaciously to the idea that it is essential to 
prescribe a low regimen for many days after labor. The erroneous- 
ness of this plan is now so thoroughly recognized that it is hardly 

» Mr. F. W. Kendle : Lancet, 1887, vol. i. p. 606, 



584 THE PUERPERAL STATE. 

necessary to argue the point. There is, however, a tendency in some 
to err in the opposite direction, which leads them to insist on the 
patient's consuming solid food too soon after delivery and before she 
has regained her appetite, thereby producing nausea and intestinal 
derangement. Our best guide in this matter is the feelings of the 
patient herself. If, as is often the case, she be disinclined to eat, 
there is no reason why she should be urged to do so. A good cup of 
beef-tea, some bread and milk, or an egg beaten up with milk, may 
generally be given with advantage shortly after delivery, and many 
patients are not inclined to take more for the first day or so. If the 
patient be hungry there is no reason why she should not have some 
more solid, but easily digested food, such as white fish, chicken, or 
sweetbread ; and, after a day or two, she may resume her ordinary diet, 
bearing in mind that, being confined to bed, she cannot with advan- 
tage consume the same amount of solid food as when she is up and 
about. Dr. Oldham, in his presidential address to the Obstetrical 
Society, 1 made some apposite remarks on this point which are worthy 
of quotation : " A puerperal month under the guidance of a monthly 
nurse is easily drawn out, and it is well if a love of the comforts of 
illness and the persuasion of being delicate, which are the infirmities 
of many women, do not induce a feeble life which long survives after 
the occasion of it is forgotten. I know no reason why, if a woman is 
confined early in the morning, she should not have her breakfast of 
tea and toast at nine, her luncheon from some digestible meat at one, 
her cup of tea at five, her dinner with chicken at seven, and her tea 
again at nine, or the equivalent, according to the variation of her 
habits of living. Of course there is the common-sense selection of 
articles of food, guarding against excess, and avoiding stimulants. 
But gruel and slops and all intermediate feeding are to be avoided.' 7 
No one who has seen both methods adopted can fail to have been 
struck with the more rapid and satisfactory convalesence which takes 
place when the patient's strength is not weakened by an unnecessarily 
low diet. Stimulants, as a rule, are not required ; but if the patient be 
weakly and exhausted, or if she be accustomed to their use, there can 
be no reasonable objection to their judicious administration. 

Attention to Cleanliness. — Immediately after delivery a warm 
napkin or pad of aseptic wool is applied to the vulva, and after the 
patient has rested a little, the nurse removes the soiled linen from the 
bed and washes the external genitals. It is impossible to pay too 
much attention during the subsequent progress of the case to the main- 
tenance of perfect cleanliness. Perfectly antiseptic midwifery is no 
doubt an impossibility, but a near approach to it may be made, and 
the greater the care taken the more certainly will the safety of the 
patient be insured. 2 It will be a wise precaution to advise the nurse 

i Obst. Trans., 1865, vol. v. p. 14. 

2 I have for the past year or two distributed the following rules to the monthly nurses attending 
my own patients, with the result, I believe, of a marked improvement in their comfort and a 
more generally satisfactory convalescence : 

ANTISEPTIC RULES FOR MONTHLY NURSES. 

1. Two bottles are supplied to each patient. One contains a mixture of perchloride of mercury, 
of the strength of 1 part to 1000 of water (called the 1 : 1000 solution), the other carbolized 
vaseline (1 : 8). 



THE PUERPERAL STATE AND ITS MANAGEMENT. 585 

never to touch the genitals foi the first few days, unless her hands 
have Urn moistened in a 1 :20 solution of carbolic acid, or 1 : L000 
solution of perchloride of mercury, or lubricated with carbolized 

vaseline. The linen should be frequently changed, and all dirty linen 
and discharges immediately removed from the apartment. Tin* vulva 
should be washed daily with a solution of perchloride of mercury of 
the strength of 1 : 2000, or with creolin and water, and the patient 
will derive great comfort from having the vagina gently syringed 
out once a day with the latter solution. Systematic douching of the 
vagina has been found prejudicial in lying-in hospitals, but in private 
practice, used as here advised, 1 am quite satisfied of its utility. The 
remarkable diminution of mortality which has followed such anti- 
septic precautions in lying-in hospitals well shows the importance of 
these measures. The room should be kept tolerably cool, and fresh 
air freely admitted. 

Action of the Bowels. — It is customary, on the morning of the 
second or third day, to secure an action of the bowels ; and there is no 
better way of doing this than by a large enema of soap and water. If 
the patient object to this, and the bowels have not acted, some mild 
aperient may be administered, such as a small dose of castor oil, a few 
grains of eoloevnth and henbane pill, or the popular French aperient, 
the " Tamar Iiidien." 

Lactation. — The management of suckling and of the breasts forms 
an important part of the duties of the monthly nurse, which the prac- 
titioner should himself superintend. This will be more conveniently 
discussed under the head of lactation. 

Importance of Prolonged Rest. — The most important part of the 
management of the puerperal state is the securing to the patient pro- 
longed rest in the horizontal position, in order to favor proper involu- 
tion of the uterus. For the first few days she should be kept as quiet 
and still as possible, not receiving the visits of any but her nearest 
relatives, thus avoiding all chance of undue excitement. It is cus- 
tomary among the better classes for the patient to remain in bed for 
eight or ten days ; but, provided she be doing well, there can be no 
objection to her lying on the outside of the bed, or slipping on to a 
sofa, somewhat sooner. After ten days or a fortnight she may be 
permitted to sit on a chair for a little, but I am convinced that the 
longer she can be persuaded to retain the recumbent position, the 
more complete and satisfactory will be the progress of involution; and 
she should not be allowed to walk about until the third week, about 

2. A small basin containing the 1 : 1000 solution must always stand by the hedside of the patient, 
and the nurse must thoroughly rinse her hands in it every time she touches the patient in the 
neighborhood of the genital organs, for washing or any other purpose whatsoever, before or during 
labor, and for a week after delivery. 

3. Pledgets of cotton-wool should be used for washing the genitals instead of sponges. 

4. Vaginal and rectal pipes, catheters, etc., must be dipped in the 1 :1000 solution before being 
used. The surfaces of slippers, bedpans, etc., should also be sponged with it. 

5. Vaginal pipes, enema-tubes, catheters, etc., should be smeared with the carbolized vaseline 
before use. 

6. Unless express directions are given to the contrary, the vagina should be syringed once daily 
after deliverv with warm water with sufficient creolin dropped into it to give it a milky hue. 

7. All soiled linen, diapers, etc., should be immediately removed from the bedroom. 

N B.— These rules are for the purpose of protecting the patient from the risk arising from acci- 
dental contamination of the hands, etc It is, therefore, hoped that they will be faithfully and 
minutely adhered to. 



586 THE PUERPERAL STATE. 

which time she may also be permitted to take a drive. If it be borne 
in mind that it takes from six weeks to two months for the uterus to 
regain its natural size, the reason for prolonged rest will be obvious. 
The judicious practitioner, however, while insisting on this point, will 
take measures at the same time not to allow the patient to lapse into the 
habits of an invalid, or to give the necessary rest the semblance of disease. 
Subsequent Treatment. — Toward the termination of the puer- 
peral month some slight tonic, such as small doses of quinine with 
phosphoric acid, may be often given with advantage, especially if con- 
valescence be tardy. Nothing is so beneficial in restoring the patient 
to her usual health as change of air, and in the upper classes a short 
visit to the seaside may generally be recommended, with the certainty 
of much benefit. 



CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Respiration. — Almost immediately after its 
expulsion, a healthy child cries aloud, thereby showing that respiration 
is established, and this may be taken as a signal of its safety. The 
first respiratory movements are excited, partially by reflex action 
resulting from the contact of the cold external air with the cutaneous 
nerves, and partly by the direct irritation of the medulla oblongata, 
in consequence of the circulation through it of blood no longer 
oxygenated in the placenta. 

Apparent Death of the Newborn Child. — INot unfrequently the 
child is born in an apparently lifeless state. This is especially likely 
to be the case when the second stage of labor has been unduly pro- 
longed, so that the head has been subjected to long-continued pressure. 
The utero-placental circulation is also apt to be injuriously interfered 
with before the birth of the child when a tardy labor has produced 
tonic contraction of the uterus, and consequent closure of the uterine 
sinuses; or, more rarely, from such causes as the injudicious adminis- 
tration of ergot, premature separation of the placenta, or compression 
of the umbilical cord. In any of these cases it is probable that the 
arrest of the utero-placental circulation induces attempts at inspira- 
tion, which are necessarily fruitless, since air cannot reach the lungs, 
and the foetus may die asphyxiated ; the existence of the respiratory 
movement being proved on post-mortem examination by the presence 
in the lungs of liquor amnii, mucus, and meconium, and by the 
extravasation of blood from the rupture of their engorged vessels. 

In most cases, when the child is born in a state of apparent asphyxia, 
its face is swollen and of a dark livid color. It not infrequently 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 587 

makes one or two feeble and gasping efforts at respiration without any 
definite cry; on auscultation the heart may be heard t<> beat weakly 
and slowly. I uder Buch circumstances there is a fair hope of its 
recovery. In other cases the child, instead of being turgid and livid 
in the face, is pale, with flaccid limbs, and no appreciable cardiac 
action; then the prognosis is much more unfavorable. 

Treatment of Apparent Death. — No time should be lost in 
endeavoring to excite respiration, and. at first, this must be done by 
applying suitable stimulants to the cutaneous nerve-, in the hope of 
exciting reflex action. The cord should be at once tied, and the child 
removed from the mother; for the final uterine contraction- have bo 
completely arrested the utero-plaoental circulation as to render it no 
longer of any value. If the face be very livid, a few drops of blood 
may with advantage be allowed to flow from the cord before it is tied, 
with the view of relieving the embarrassed circulation. Very often 
some slight stimulus, such as onv or two sharp slaps on the thorax, or 
rapidly rubbing the body with brandy poured into the palms of the 
hands, will suffice to induce respiration. Failing this, nothing act- so 
well as the sudden and instantaneous applieation of heat and cold. 
For this purpose extremely hot water is placed in one basin, and 
quite cold water in another. Taking the child by the shoulders and 
lei-, it should be dipped for a single moment into the hot water, and 
then into the cold ; and these alternate applications may be repeated 
once or twice, as occasion requires. The effect of this measure is often 
very marked, and I have frequently seen it succeed when prolonged 
efforts at artificial respiration have been made in vain. 

If the-e means fail, an endeavor must be at ouce made to carry on 
respiration artificially. The best means of doing this have been ex- 
ha i-tively studied by Dr. Champneys. 1 who considers the only two 
reliable means of carrying on artificial respiration are those of Schultze 
and Sylvester. The Sylvester method is. on the whole, that which is 
most easily applied, and. on account of the compressibility of the 
thorax, it is peculiarly -uitable for infants. The child being laid on 
its back, with the shoulders slightly elevated and the feet held in an 
elongated position by an assistant, the elbows are grasped by the 
operator, and alternately raised above the head, and slowly depressed 
against the sides of the thorax, being at the same time everted, so as 
to produce the effect of inspiration and expiration. In Schultze's 
method the child is grasped on either side of the thorax, the operator's 
thumbs being anterior, the index lingers being in the axillae, and the 
remaining fingers on the child's back. The operator's arms are now 
bed out -o that the child hangs at arm's length between his knees. 
By this means the chest is expanded, aud inspiratory movement- are 
produced. The operator's arm- are now swung upward until they 
are horizontal. This causes the child'- body to be flexed, its head is 
directed downward, and it- legs fall toward the operator until the 
weight of its body rests on his thumbs. By this mean- its thorax and 
abdomen are compressed, it- diaphragm i- forced upward, and expira- 

1 Medico-Chir. Trans., vol. lxiv. pp. 41, ST, and vol. Ixv. p. 75. 



588 THE PUERPERAL STATE. 

tion results. If now the child be again swung into its former position, 
inspiration fellows. 

Other means of exciting respiration have been recommended. One 
of them, much used abroad, is the artificial insufflation of the lungs 
by means of a flexible catheter guided into the glottis, or by placing 
a handkerchief over the child's mouth and directly insufflating the 
longs. It is not difficult to pass the end of a catheter into the glottis, 
using the little finger as a guide ; and once in position, it may be used 
to blow air gently into the lungs, which is expelled by compression on 
the thorax, the insufflation being repeated at short intervals of about 
ten seconds. One advantage of this plan is that it allows the liquor 
aninii and other fluids, which may have been drawn into the lungs in 
the premature efforts at respiration before birth, to be sucked up into 
the catheter, and so removed from the lungs. Dr. Ghampneys recom- 
mends that when the catheter is passed into the trachea for about three 
inches from the child's mouth, the thorax should be gently compressed, 
and then air should be blown through the catheter. The effect of this 
manoeuvre is that any mucus or fluids in the trachea pass upward 
through the glottis into the pharynx. The same effect may be pro- 
duced, but less perfectly, by placing the hand over the nostrils of the 
child, blowing into its mouth, and immediately afterward compressing 
the thorax. One of these methods should certainly be tried if all 
other means have failed. Faradization along the course of the phrenic 
nerve is a promising means of inducing respiration, which should be 
used if the proper apparatus can be procured. Encouragement to 
persevere in our endeavors to resuscitate the child may be derived 
from the numerous authenticated instances of success after the lapse 
of a considerable time, even of an hour or more. As long as the 
cardiac pulsations continue, however feebly, there is no reason to 
despair, and Ghampneys has collected soine apparently authenticated 

—-in which children seemingly dead have been buried : r -onie 
hours and then dug up and restored to life. 

Washing and Dressing- of the Child. — When the child cries 
lustily from the first, it is customary for the nurse to wash aud dn 56 
it as soon as her immediate attendance on the mother is no longer 
required. For this purpose it is placed in a bath of warm water, and 
carefully soaped and sponged from head to foot "With the view of 
facilitating the removal of the unctuous material with which it is 
covered, it is usual to anoint it with cold cream or olive oil, which is 
washed off in the bath. Nurses are apt to use undue roughness in 
endeavoring to rem ry particle of the vernix caseosa, small 

portions of which are often firmly adherent. This mistake should be 
avoided, as these particles will soon dry up and become spontaneously 
detached. The cord is generally wrapped in a small piece of charred 
linen, which is supposed to have some slight antiseptic property, and 
this is renewed from day to day until the cord has withered and sepa- 
rated. This generally occurs within a week ; and a small pad of soft 
linen is then placed over the umbilicus, and supported by a flannel 
belly-band placed around the abdomen, which should not be too tight, 



ff A61M1NT OF THE IB LACTATION. ETC. 589 

for ssing 1 spiration. By this m lency 

abilical hernia is prevent 

The clothing of the infant vari - ling 1 - and the 

9 of the parents. The important - r in mind 

are that it should be warm - - rn children are extremely 

- - ad at the same time liirht and sufficiently loose 

to allow free play imbs ami thorax. All tight bandaging 

_ - - s - imon in - rte of 1 I tinent, 

should be avoided, and - - stened by strings or by 

sewing, - ing used. At the present day it is 

- - that the head may be kept cool. The ntmost possible 
attenti.-n should be paid to cleanliness, and the child should a - 

larly bathed in tej - ily, and after tin 

weeks, both nig 1 morning. After drying, the flexures of the 

2 - and arms, and the nat- s, s 1 be dusted with violet p 

or fuller's earth, to prevent chafing of the skin. The excrements 
should be 1 in napkins wrapped around the hips, and _ 

care is required to change the napkin- as often as they are wet or 
soiled, otherwise troublesome irritation will arise. A neg :' this 

precaution, and the washing of the napkins with o - s or & 
are among the principal cs ises :' the eruptions and excoriations - 
common in badly-cared-for children. When washed and ssed the 
child may be placed in its cradle, and covered with soft blankets 
eider-down quilt. 

As s - the mother has sted a little, it is advisable to place the 

child to the breast. This is useful to the mother by favoring uterine 
contraction. Even now there is in the breasts a variable quantity of 
the peculiar fluid known as i. This is a viscid yell ie 

"ion, different in appearance from the thin bluish milk which is 
subsequently- formed. Examined under the microscope it is found to 
conta: - milk-gl Lea a number of large granular and 

small fat • scles. It has a | orgative property, and soon produces, 

with less irritation than any of the laxatives - _ merally used, a dis- 
charge of the meconium with which the bowels are loaded. Hence 
the accoucheur should prohibit the common practice of administering 
other aperient, within the first few days after birth. 
although there can be no objection to it in special cases, if the bowels 
app ntly and with difficulty. 

Over-frequent Suckling should be Avoided. — For the first few 
5, and until th - tion of milk is thoroughly established, the 
child should be put to the breast at long intervals only. Constant 
attempts at suckling an empty breast lead to nothing but disappoint- 
ment, both to the mother and child, and. by unduly irritating the 
mamma?. sometinu b sitive harm. Therefore, for the first <1 

two, it is sufficient if the child be applied t<:> the breast r 
most til s, in 1 I enty-four hours. Nor is it necessary to be 

apprehensive, as many mothers naturally are. that the child will suffer 

: • i. A few spoonfuls of milk and water _ _ 

from time to time, the child may generally wait without injury until 
the milk is secreted. This isg it the third day. when the 






590 THE PUERPERAL STATE. 

secretion is found to be a whitish fluid, more watery in appearance 
than cow's milk, and showing under the microscope an abundance of 
minute spherical globules, refracting light strongly, which are abun- 
dant in proportion to the quality of the milk. A certain number of 
granular corpuscles may also be observed shortly after the birth of the 
child, but after the first month these should have almost or altogether 
disappeared. The reaction of human milk is decidedly alkaline, and 
the taste much sweeter than that of cow's milk. 

The importance to the mother of nursing her own child, whenever 
her health permits, on account of the favorable influence of lactation 
in promoting a proper involution of the uterus, has already been in- 
sisted on. Unless there be some positive contra-indicatiou, such as a 
marked strumous cachexia, an hereditary phthisical tendency, or great 
general debility, it is the duty of the accoucheur to urge the mother to 
attempt lactation, even if it be not carried on more than a month or 
two. It is, however, the fact that in the upper classes of society a 
large number of patients are unable to nurse, even though willing 
and anxious to do so. In some there is hardly any lacteal secretion 
at all, in others there is at first an over-abundance of watery and in- 
nutritious milk, which floods the breasts and soon dies away alto- 
gether. Something analogous to this result of breeding and culture is 
observed in the lower animals. Thus in the so-called " pedigree " 
cattle, the cow is never able to nurse its calf; and the same is observed, 
though less constantly, in thoroughbred racing stock. 

"When the Mother cannot Nurse, a "Wet-nurse should be Pro- 
cured. — Whenever the mother cannot or will not nurse, the question 
will arise as to the method of bringing up the child. From many 
causes there is an increasing tendency to resort to bottle-feeding, in- 
stead of procuring the services of a wet-nurse, even when the question 
of expense does not come into consideration. Xo long experience is 
required to prove that hand-feeding is a bad and imperfect substitute 
for Nature's mode, and one which the practitioner should discourage 
whenever it lies in his power to do so. It is true that, in many cases, 
bottle-fed children do well ; but there is good reason to believe that, 
even when apparently most successful, the children are not so strong 
in after life as they would have been had they been brought up at the 
breast. ^Vhen, in addition, it is borne in mind how much of the 
success of hand-feeding depends on intelligent care on the part of the 
nurse, what evils are apt to accrue from the injurious selection of food, 
and from ignorance of the commonest laws of dietetics, there is 
abundant reason for urging the substitution of a wet-nurse whenever 
the mother is unable to undertake the suckling of her child. It must 
be admitted that good hand-feeding is better than bad wet-nursing, 
and the success of the latter hinges on the proper selection of a wet- 
nurse. As this falls within the duties of the practitioner, it will be 
well to point out the qualities which should be sought for in a wet- 
nurse, before proceeding to discuss the mode of rearing the child at 
the breast. 

Selection of a Wet-nurse. — In selecting a wet-nurse we should 
endeavor to choose a strong, healthy woman, who should not be over 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 591 

thirty or thirty-five years of age at the outside 4 , since the quality of 
the milk deteriorates in women who are more advanced in life. For 
a similar reason a very young woman of sixteen or seventeen should 
be rejected. It is needless to say that care must be taken to ascertain 
the absence of all traces of constitutional disease, especially marks of 
scrofula, or enlarged cervical or inguinal glands, which may possibly 
be due to antecedent syphilitic taint. If the nurse be of good mus- 
cular development, healthy-looking, with a clear complexion, and 
sound teeth (indicating a generally good state of health), the color of 
the hair and eyes is of secondary importance. It is commonly stated 
that brunettes make better nurses than blondes, but this is by no 
means necessarily the case; and provided all the other points be favor- 
able, fairness of skin and hair need be no bar to the selection of a 
nurse. The breasts should be pear-shaped, rather firm, as indicating 
an abundance of gland-tissue, and with the superficial veins well 
marked. Large, flabby breasts owe much of their size to an undue 
deposit of fat, and are generally unfavorable. The nipple should be 
prominent, not too large, and free from cracks and erosions, which, if 
existing, might lead to subsequent difficulties in nursing. On press- 
ing the breast the milk should flow from it easily in a number of 
small jets, and some of it should be preserved for examination. It 
should be of a bluish-white color, and when placed under the micro- 
scope the field should be covered with an abundance of milk corpus- 
cles, and the large granular corpuscles of the colostrum should have 
entirely disappeared. If the latter be observed in any quantity in a 
woman who has been confined five or six weeks, the inference is that the 
milk is inferior in quality. It is not often that the practitioner has an 
opportunity of inquiring into the moral qualities of the nurse, although 
much valuable information might be derived from a knowledge of her 
previous character. An irascible, excitable, or highly nervous woman 
will certainly make a bad nurse, and the most trivial causes might 
afterward interfere with the quality of her milk. Particular attention 
.should be paid to the nurse's own child, since its condition affords the 
best criterion of the quality of her milk. It should be plump, well- 
nourished, and free from all blemishes. If it be at all thin and 
wizened, especially if there be any snuffling at the nose, or should any 
eruption exist affording the slightest suspicion of a syphilitic taint, the 
nurse should be unhesitatingly rejected. 

Management of Suckling. — The management of suckling is much 
the same whether the child is nursed by the mother or by a wet- 
nurse. As soon as the supply of milk is sufficiently established, the 
child must be put to the breast at short intervals, at first of about two 
hours, and, in about a month or six weeks, of three hours. From 
the first few days it is a matter of the greatest importance, both to the 
mother and child, to acquire regular habits in this respect. If the 
mother gets into the way of allowing the infant to take the breast 
whenever it cries, as a means of keeping it quiet, her owu health must 
soon suffer, to say nothing of the discomfort of being incessantly tied 
to the child's side; while the child itself has not sufficient rest to 
digest its food, and very shortly diarrhoea or other symptoms of 



592 THE PUERPERAL STATE. 

dyspepsia are pretty sure to follow. After a month or two the infant 
should be trained to require the breast less often at night, so as to 
enable the mother to have an undisturbed sleep of six or seven hours. 
For this purpose she should arrange the times of nursing so as to give 
the breast just before she goes to bed, and not again until the early 
morning. If the child should require food in the interval, a little 
milk in water, from the bottle, may be advantageously given. 

Diet of Nursing- Women. — The diet of the nursing woman should 
be arranged on ordinary principles of hygiene. It should be abundant, 
simple, and nutritious, but all rich and stimulating articles of food 
should be avoided. A common error in the diet of wet-nurses is over- 
feeding, which constantly leads to deterioration of the milk. Many 
of these women, before entering on their functions, have been living 
on the simplest and even sparest diet, and not uncommonly, in the 
better class of houses, they are suddenly given heavy meat meals three 
and even four times a day, and often three or four glasses of stout. It 
is hardly a matter of astonishment that, under such circumstances, 
their milk should be found to disagree. For a nursing woman in good 
health two good meat meals a day, with two glasses of beer or porter, 
and as much milk and bread-and-butter as she likes to take in the 
intervals, should be amply sufficient. Plenty of moderate exercise 
should be taken, and the more the nurse and child are out in the open 
air, provided the weather be reasonably fine, the better it is for both. 

[Usually the wet-nurses employed in our cities are of foreign birth ; 
where thev are natives, their children are commonlv illegitimate. An 
American nurse is in general preferable, and as a rule those making 
application have not been in the habit of using malt drinks. A healthy 
woman will usually nurse well on her ordinary diet, which should be 
largely farinaceous. Ale is often recommended to nursing mothers, 
and so also is tea, but both are very inferior to milk and farinaceous 
diets prepared with milk. Broma prepared with cream I have seen 
taken once a day, for a change, with advantage. — Ed.] 

Signs of Successful Lactation. — Carried on methodically in this 
manner, wet-nursing should give but little trouble. In the intervals 
between its meals the child sleeps most of its time, and wakes with 
regularity to feed ; but if the child be wakeful and restless, cry after 
feeding, have disordered bowels, and, above all, if it do not gain, week 
by week, in weight (a point which should be, from time to time, ascer- 
tained by the scales), we may conclude that there is either some grave 
defect in the management of suckling, or that the milk is not agreeing. 
Should this unsatisfactory progress continue, in spite of our endeavors 
to remedy it, there is no resource left but the alteration of the diet, 
either by changing the nurse or by bringing up the child by hand. 
The former should be preferred whenever it is practicable, and in the 
upper ranks of life it is by no means rare to have to change the wet- 
nurse two or three times before one is met with whose milk agrees 
perfectly. If the child have reached six or seven months of age, it 
may be preferable to wean it altogether, especially if the mother has 
nursed it, as hand-feeding is much less objectionable if the infant has 
had the breast for even a few months. 



MANAGEMENT OF THI INFANT, LACTATION, ETC. 593 

Period of Weaning. — As a rule, weaning should not be attempted 
until dentition is fairly established, that being the sign that Nature has 
prepared the child for an alteration of food ; and it is better that the 
main portion of the diet should be breast milk until at leasl Bis or 
seven teeth have appeared. This is a safer guide than any arbitrary 
rule taken from the age of the child, since the commencement of den- 
tition varies much in different cases. About the sixth or Beventh 
month it is a good plan to commence the use of some suitable artificial 
food once a day, so as to relieve the strain on the mother or nurse, and 
prepare the child for weaning, which should always be a very gradual 
process. In this waya meal of rusks of entire wheat-flour, or of hect- 
or chicken-tea. with bread-crumb in it, may be given with advantage; 
and as the period for weaning arrives a second meal may be added, 
and so eventually the child may be weaned without distress to itself or 
trouble to the nurse. 

The disorders of lactation are numerous, and as they frequently 
come under the notice of the practitioner, it is necessary to allude to 
some of the most common and important. 

Means of Arresting- the Secretion of Milk. — The advice of the 
accoucheur is often required in cases in which it has been determined 
that the patient is not to nurse, when we desire to get rid of the milk 
3 6 on as possible, or when, at the time of weaning, the same object is 
sought. The extreme heat and distention of the breasts, in the former 
class of cases, often give rise to much distress. A smart saline aperient 
will aid in removing the milk, and for this purpose a double Seidlitz 
powder, or frequent small doses of sulphate of magnesia, act well ; 
while, at the same time, the patient should be advised to take as small 
a quantity of fluid as possible. Iodide of potassium in large doses of 
twenty or twenty-live grains, repeated twice or thrice, has a remarkable 
etfect in arresting the secretion of milk. This observation was first 
empirically made by observing that the secretion of milk was arrested 
Avhen this drug was administered for some other cause ; and I have 
frequently found it answer remarkably well. The distention of the 
breasts is best relieved by covering them with a layer of lint or eotton- 
wool, soaked in a spirit lotion or eau de Cologne and water, over which 
oiled silk is placed, and by directing the nurse to rub them gently with 
warm oil, whenever they get hard and lumpy. Breast-pumps and 
similar contrivances only irritate the breasts, and do more harm than 
good. The local application of belladonna has been strongly recom- 
mended as a means for preventing lacteal secretion. As usually 
applied, in the form of belladonna plaster, it is likely to prove hurtful, 
since the breast often enlarges after the plasters are applied, and the 
pressure of the unyielding leather on which they are spread produces 
intense suffering. A better way of using it is by rubbing down a 
drachm of the extract of belladonna with an ounce of glycerin, and 
applying this on lint. In some cases it answers extremely well; but 
it is very uncertain in its action, and frequently is quite useless. 

Defective Secretion of Milk. — A deficiency of milk in nursing- 
mothers is a very common source of difficulty. In a wet-nurse this 
drawback is, of course, an indication for changing the nurse : but to 



594 THE PUERPERAL STATE. 

the mother the importance of nursing is so great that an endeavor 
must be made either to increase the now of milk or to supplement it 
by other food. Unfortunately, little reliance can be placed on any of 
the so-called galactagogues. The only one which in recent times has 
attracted attention is the leaves of the castor-oil plant, which, made 
into poultices and applied to the breast, are said to have a beneficial 
effect in increasing the flow of milk. More reliance may be placed in 
a sufficiency of nutritious food, especially such as contains phosphatic 
elements ; stewed eels, oysters, and other kinds of shell-fish, and the 
Revalenta Arabica, are recommended by Dr. Routh, who has paid some 
attention to this point, 1 as peculiarly appropriate. If the amount of 
milk be decidedly deficient, the child should be less often applied to 
the breast, so as to allow milk to collect, and properly prepared cow's 
milk from a bottle should be given alternately with the breast. This 
mixed diet generally answers well, and is far preferable to pure hand- 
feeding. 

[There is no diet equivalent to milk for a nursing-mother, where it 
agrees with her. This I have tested repeatedly in women who had 
failed entirely in former attempts to nurse their infants. One lady who 
had lost her milk three times at the end of a month, and had nursed 
two babies into starvation, was enabled to nurse her fourth while on a 
milk diet for eighteen months, and gained while doing so nineteen 
pounds. Another gained sixty-five pounds while nursing, and her son 
was very large for his age. A third lost a child by hand-feeding, and 
nursed the next infant on a milk diet, at the same time becoming fatter 
than she had ever been. A decided advantage in the use of milk is, 
that it prevents the exhausted feeling so common with delicate nursing 
mothers. I have had a patient of eighty-six pounds weight use two 
quarts of milk a day, and at the same time eat her usual measure of 
food, which had always been of small amount. — Ed.] 

Depressed Nipples. — A not uncommon source of difficulty is a 
depressed condition of the nipples, which is generally produced by the 
constant pressure of the stays. The result is that the child, unable to 
grasp the nipple, and wearied with ineffectual efforts, may at last refuse 
the breast altogether. An endeavor should be made to elongate the 
nipple before putting it into the child's mouth, either by the fingers or 
by some form of breast-pump, which here finds a useful application. 
In the worst class of cases, when the nipple is permanently depressed, 
it may be necessary to let the child suck through a glass nipple-shield, 
to which is attached an India-rubber tube similar to that of a sucking- 
bottle ; this it is generally well able to do. 

Fissures and Excoriations of the Nipples. — Fissures and excoria- 
tions of the nipples are common causes of suffering, in some cases 
leading to mammary abscess. \Thenever the practitioner has the 
opportunity, he should advise his patient to prepare the nipple for 
nursing in the latter months of pregnancy ; and this may best be done 
by daily bathing it with a spirituous or astringent lotion, such as eau 
de Cologne and water or a weak solution of tannin. After nursing 

1 Eoutli on Infant-feeding, 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 595 

has begun great cart 1 should be taken to wash and dry the nipple after 
the child has been applied to it, and, as long as the mother is in the 
recumbent position, she may, it the topples be at all tender, use zinc 
nipple-shields with advantage when she is not nursing, In this way 
these troublesome complications may generally be prevented. The 
most common forms are either an abrasion on the surface of the nipple, 
which, if neglected, may form a small ulcer, or a crack at some part 
of the nipple, most generally at its base. In either case, the Buffering 
when the child is put to the breast is intense 4 , sometimes indeed amount- 
ing to intolerable anguish, causing the mother to look forward with 
dread to the application of the child. Whenever such pain is com- 
plained of, the nipple should be carefully examined, since the fissure 
or sore is often so minute as to escape superficial examination. The 
remedies recommended are very numerous and not always successful. 
Amongst those most commonly used arc astringent applications, such 
as tannin or weak solutions of nitrate of silver, or cauterizing the 
edges of the fissure with solid nitrate of silver, or applying the flexible 
collodion of the Pharmacopoeia. Dr. Wilson, of Glasgow, speaks 
highly of a lotion composed of ten grains of nitrate of lead in an 
ounce of glycerin, which is to be applied after suckling, the nipple 
being carefully washed before the child is again put to the breast. I 
have myself found nothing answer so well as a lotion composed of 
half an ounce of sulphurous acid, half an ounce of the glycerin of 
tannin, and an ounce of water, the beneficial effects of which are some- 
times quite remarkable. Relief may occasionally be obtained by 
inducing the child to suck through a nipple-shield, especially when 
there is only an excoriation ; but this will not always answer, on 
account of the extreme pain which it produces. 

Excessive Flow of Milk. — An excessive flow of milk, known as 
galadorrhoea, often interferes with successful lactation. It is by no 
means rare in the first weeks after delivery for women of delicate con- 
stitutions who are really unfit to nurse, to be flooded with a super- 
abundance of watery and innutritions milk, which soon produces 
disordered digestion in the child. Under such circumstances the only 
thing to be done is to give up an attempt which is injurious both to 
the mother and child. At a later stage the milk, secreted in large 
quantities, is siulficiently nourishing to the child, but the drain on the 
mother's constitution soon begins to tell on her. Palpitation, giddi- 
ness, emaciation, headache, loss of sleep, spots before the eyes, indicate 
the serious effects which are being produced, and the absolute necessity 
of at once stopping lactation. Whenever, therefore, a nursing-woman 
suffers from such symptoms, it is far better at once to remove the 
cause, otherwise a very serious and permanent deterioration of health 
might result. When, tinder such circumstances, nursing is unwisely 
persevered in, most serious results may follow. Should any diathetic 
tendency exist, especially when there is a predisposition to phthisis, 
nothing is so likely to develop it as the debility produced by excessive 
jactation. Certain diseases of the eye are then specially apt to occur, 
such as severe inflammation of the cornea, leading to opacity and even 



596 THE PUERPERAL STATE. 

sloughing, and certain forms of choroiditis ; also impairment of accom- 
modation due to defective power of the ciliary muscle. 1 

Mammary Abscess. — There is no .more troublesome complication 
of lactation than the formation of abscess in the breast ; an occurrence 
by no means rare, and which, if improperly treated, may, by long- 
continued suppuration and the formation of numerous sinuses in and 
about the breast, produce very serious effects on the general health. 
The causes of breast abscesses are numerous, and very trivial circum- 
stances may occasionally set up inflammation ending in suppuration. 
Thus it may follow exposure to cold, a blow or other injury to the 
breast, some temporary engorgement of the lacteal tubes, or even 
sudden or depressing mental emotions. The most frequent cause is 
irritation from fissures or erosions of the nipple, which must there- 
fore always be regarded with suspicion and cured as soon as possible. 

It has of late years been held that mammary abscess generally arises 
from septic infection through such fissures, an idea first suggested by 
Kaltenbach. Since that date pyogenic microbes have generally been 
detected in puerperal mammary abscesses. It is considered possible 
that infective microbes may find an entrance through the openings of 
the lactiferous ducts, when no fissures exist. 2 These considerations 
obviously point to the necessity of extreme care and cleanliness in all 
nursing- women. 

The abscess may form in any part of the breast, or in the areolar 
tissue below it ; in the latter case, the inflammation very generally 
extends to the gland structure. Abscess is usually ushered in by con- 
stitutional symptoms, varying in severity with the amount of the 
inflammation. Pyrexia is always present ; elevated temperature, rapid 
pulse, and much malaise and sense of feverishness, followed, in many 
cases, by distinct rigor, when deep-seated suppuration is taking place. 
On examining the breast it will be found to be generally enlarged and 
very tender, while at the site of the abscess an indurated and painful 
swelling may be felt. If the inflammation be chiefly limited to the 
sub-glandular areolar tissue, there may be no localized swelling felt, 
but the whole breast will be acutely sensitive and the slightest move- 
ment will cause much pain. As the case progresses, the abscess 
becomes more and more superficial, the skin covering it is red and 
glazed, and if left to itself it bursts. In the more serious cases it is 
by no means rare for multiple abscesses to form. These, opening one 
after the other, lead to the formation of numerous fistulous tracts, by 
which the breast may become completely riddled. Sloughing of por- 
tions of the gland tissue may take place, and even considerable hemor- 
rhage from the destruction of bloodvessels. The general health soon 
suffers to a marked degree, and, as the sinuses continue to suppurate 
for many successive months, it is by no means uncommon for the 
patient to be reduced to a state of profound and even dangerous 
debility. 

1 See Foerster, of Breslau, in Graefe and Saernisch's Handbuch des Gesammten Augenheilkunde, 
and Power on " The Diseases of the Eye in Connection with Pregnancy," Lancet, 1880, vol. i. p, 
709 et seq. 

2 See Dr. J, Watt Black's Inaugural Address, Obstet. Trans., vol. xxxii. p. 97. 



MANAGEMENT OF THE IN FA XT. LACTATION, ETC. 597 

Treatment. — Much may be done by proper oare to prevent the 
formation of a specially by removing engorgement of the lacteal 

ducts, when threatened, by gentle hand-friction in the manner already 
indicated. When the general symptoms and the local tenderness 
indicate that inflammation has commenced, we should at once endeavor 
to moderate it. in the hope that resolution may occur without the for- 
mation of pus. ETeregeneral principles must be attended to. especially 
giving the affected part as much rest as possible. Feverishness may 
l>e combated by gentle salines, minute doses of aconite, and large doses 
of quinine; while pain should be relieved by opiates. The patient 
should he strictly confined in bed, and the affected breast supported by 
a suspensory bandage. Warmth and moisture are the best mean- of 
relieving the local pain, either in the form of hot fomentations or of 
light poultices of linseed-meal or bread and milk, and the breast may 
.cared with extract of belladonna rubbed down with glycerin, or 
the belladonna liniment sprinkled over the surface of the poultices. 
The local application of ice in India-rubber bags has been highly ex- 
tolled as a means of relieving the pain and tension, and it is said to 
be much more effectual than heat and moisture 1 Generally the pain 
and irritation produced by putting the child to the breast are so great 
a- to contra-indicate nursing from the affected side altogether, and we 
must trust to relieving the tension by poultices : suckling being, in the 
meantime, carried on at the other breast alone. In favorable cases 
this i- quite possible for a time, and it may be that, if the inflammation 
do not end in suppuration, or if the abscess be small and localized, the 
affected breast is again able to resume its functions. Often this is not 
possible, and it may be advisable, in severe cases, to give up nursing 
altogether. 

The subsequent management of the case consists in the opening of 
the abscess as soon as the existence of pus is ascertained, either by 
fluctuation, or, if the site of the abscess be deep-seated, by the exploring- 
needle. It may be laid down as a principle, that the sooner the pus 
i- evacuated the better, and nothing is to be gained by waiting until 
it is superficial. On the contrary, such delay only leads to more 
extensive disorganization of tissue, and the further spread of inflam- 
mation. 

The method of opening- the abscess is of primary importance. 
Care should be taken to make the incision in a line radiating from the 
nipple, so as to avoid cutting across the ducts. It has formerly been 
customary simply to open the abscess at its most dependent part, 
without using any precaution against the admission of air. and after- 
ward to treat secondary abs sses in the same way. The results are 
well known to all practical accoucheurs, and the records of surgery 
fully show how many weeks or month- generally clap-;- in bad cases 
befon ry i- complete. The antiseptic treatment of mammary 

- — . in the May first pointed out by Lister, affords results which 
are of the most remarkable and satisfactory kind. Instead of being 
weeks and months in healing, I believe that the practitioner who fairly 

1 Corson!: Amer. Journ. of Obstet., 1881, vol. xiv. p. 1-. 



598 THE PUERPERAL STATE. 

and minutely carries out Sir Joseph Lister's directions may confidently 
look for complete closure of the abscess in a few days ; and I know 
nothing in the whole range of my professional experience that has 
given me more satisfaction than the application of this method to 
abscesses of the breast. The plan I first used is that recommended by 
Lister in the Lancet for 1867, but which is now superseded by his im- 
proved methods, which, of course, will be used in preference by all 
who have made themselves familiar with the details of antiseptic sur- 
gery. The former, however, is easily within the reach of everyone, 
and is so simple that no special skill or practice is required in its 
application ; whereas the more perfected antiseptic appliances will 
probably not be so readily obtained, and are much more difficult to 
use. I therefore insert Sir Joseph Lister's original directions, which 
he assures me are perfectly antiseptic, for the guidance of those who 
may not be able to obtain the more elaborate dressings : "A solution 
of one part of crystallized carbolic acid in four parts of boiled linseed 
oil having been prepared, a piece of rag from four to six inches square 
is dipped into the oily mixture and laid upon the skin where the inci- 
sion is to be made. The lower edge of the rag being then raised, while 
the upper edge is kept from slipping by an assistant, a common 
scalpel or bistoury dipped in the oil is plunged into the cavity of the 
abscess, and an opening about three-quarters of an inch in length is 
made, and the instant the knife is withdrawn the rag is dropped upon 
the skin as an antiseptic curtain, beneath which the pus flows out into 
a vessel placed to receive it. The cavity of the abscess is firmly 
pressed, so as to force out all existing pus as nearly as may be (the old 
fear of doing mischief by rough treatment of the pyogenic membrane 
being quite ill-founded) ; and if there be much oozing of blood, or if 
there be considerable thickness of parts between the abscess and the 
surface, a piece of lint dipped in the antiseptic oil is introduced into 
the incision to check bleeding and prevent primary adhesion, which is 
otherwise very apt to occur. The introduction of the lint is effected 
as rapidly as may be, and under the protection of the antiseptic rag. 
Thus the evacuation of the original contents is accomplished with per- 
fect security against the introduction of living germs. This, however, 
would be of no avail unless an antiseptic dressing could be applied 
that would effectually prevent the decomposition of the stream of pus 
constantly flowing out beneath it. After numerous disappointments, 
I have succeeded with the following, which may be relied upon as abso- 
lutely trustworthy : About six teaspoonfuls of the above-mentioned solu- 
tion of carbolic acid in linseed oil are mixed up with common whiting 
(carbonate of lime) to the consistence of a firm paste, which is, in fact, 
glazier's putty with the addition of a little carbolic acid. This is 
spread upon a piece of common tinfoil about six inches square, so as 
to form a layer about a quarter of an inch thick. The tinfoil, thus 
spread with putty, is placed upon the skin, so that the middle of it 
corresponds to the position of the incision, the antiseptic rag used in 
opening the abscess being removed the instant before. The tin is then 
fixed securely by adhesive plaster, the lowest edge being left free for 
the escape of the discharge into a folded towel placed over it and 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 599 

secured by a bandage. The dressing is changed, as ;i genera] rule, 
once in twenty-four hours, but, if the abscess be a very large one, it is 
prudent to see the patient twelve hours after it has been opened, when, 
if the towel should be much stained with discharge, the dressing should 
be changed, to avoid subjecting its antiseptic virtues to too severe a 
test. But after the first twenty-four hours a single daily dressing is 
sufficient. The changing of the dressing must be methodically done 
as follows: A second similar pieee of tinfoil having been spread with 
the putty, a piece of rag is dipped in the oily solution and placed on 
the incision the moment the first tin is removed. This guards against 
the possibility of mischief occurring during the cleansing of the skin 
with a dry cloth, and pressing out any discharge which may exist in 
the cavity. If a plug of lint was introduced when the abscess was 
opened, it is removed under cover of the antiseptic rag, which is taken 
otf at the moment when the new tin is to be applied. The same pro- 
cess is continued daily until the sinus closes." 

Treatment of Long-continued Suppuration. — If the case come 
under our care when the abscess has been long discharging, or when 
sinuses have formed, the treatment is directed mainly to procuring a 
cessation of suppuration and closure of the sinuses. For this purpose 
methodical strapping of the breast with adhesive plaster, so as to afford 
steady support and compress the opposing pyogenic surfaces, will give 
the best results. It may be necessary to lay open some of the sinuses, 
or to inject tinct. iodi or other stimulating lotions, so as to moderate 
the discharge, the subsequent surgical treatment varying according to 
the requirements of each case. In such neglected cases Billroth recom- 
mends that, after the patient has been anaesthetized, the openings 
should be dilated so as to admit the finger, by which the septa between 
the various sinuses should be broken down and a large single abscess- 
cavity made. This should then be thoroughly irrigated with a 3 per 
cent, solution of carbolic acid, a drainage-tube introduced, and the 
ordinary antiseptic dressings applied. As the drain on the system is 
great, and the constitutional debility generally pronounced, much atten- 
tion must be paid to general treatment ; and abundance of nourishing 
food, appropriate stimulants, and such medicines as iron and quinine, 
will be indicated. 

Hand-feeding". — In a considerable number of cases the inability of 
the mother to nurse her child, her invincible repugnance to a wet- 
nurse, or inability to bear the expense, renders hand-feeding essential. 
It is, therefore, of importance that the accoucheur should be thoroughly 
familiar with the best method of bringing up the child by hand, so as 
to be able to direct the process in the way that is most likely to be 
successful. 

Much of the mortality following hand-feeding may be traced to 
unsuitable food. Among the poorer classes especially there is a 
prevalent notion that milk alone is insufficient; and hence the almost 
universal custom of administering various farinaceous foods, such as 
corn-flour or arrowroot, even from the earliest period. Many of these 
consist of starch alone, and are therefore absolutely an suited for 
forming the staple of diet, on account of the total absence of nitro- 



600 THE PUERPERAL STATE. 

genized elements. Independently of this, it has been shown that the 
saliva of infants has not the same digestive property on starch that 
it subsequently acquires, and this affords a further explanation of its 
so constantly producing intestinal derangement. Reason as well as 
experience abundantly proves that the object to be aimed at in hand- 
Feeding is to imitate as nearly as possible the food which Nature sup- 
l plies for the newborn child, and, therefore, the obvious course is to use 
milk from some animal, so treated as to make it resemble human milk 
as nearly as may be. 

Of the various milks used, that of the ass, on the whole, most closely 
resembles human milk, containing less casein and butter, and more 
saline ingredients. It is not always easy to obtain, and in towns it is 
excessively expensive. Moreover, it does not always agree with the 
child, being apt to produce diarrhoea. We can, however, be more 
certain of its being unadulterated, Avhich in large cities is in itself no 
small advantage, and it may be given without the addition of water 
or sugar. 

Goat's milk in England is still more difficult to obtain, but it often 
succeeds admirably. In many places the infant sucks the teat directly, 
and certainly thrives well on this plan. 

Cow's Milk and its Preparation. — In a large majority of cases we 
have to rely on cow's milk alone. It differs from human milk in con- 
taining less water, a larger amount of casein and solid matters, and less 
sugar. Therefore, before being given it requires to be diluted and 
sweetened. A common mistake is over-dilution, and it is far from 
rare for nurses to administer one-third cow's milk to two-thirds water. 
The result of this excessive dilution is, that the child becomes pale and 
puny, and has none of the firm and plump appearance of a well-fed 
infant. The practitioner should, therefore, ascertain that this mistake 
is not being made ; and the necessary dilution will be best obtained by 
adding to pure fresh cow's milk one-third hot water, so as to warm 
the mixture to about 96°, the whole being slightly sweetened with 
sugar of milk or ordinary crystallized sugar. After the first two or 
three months the amount of water may be lessened, and pure milk, 
warmed and sweetened, given instead. Whenever it is possible, the 
milk should be obtained from the same cow, and in towns some care 
is requisite to see that the animal is properly fed and stabled. Of late 
years it has been customary to obviate the difficulties of obtaining good 
fresh milk by using some of the canned milks now so easily to be had. 
These are already sweetened, and sometimes answer well if not given 
in too weak a dilution. One great drawback in bottle-feeding is the 
tendency of the milk to become acid, and hence to produce diarrhoea. 
This may be obviated to a great extent by adding a tablespoonful of 
lime-water to each bottle, instead of an equal quantity of water. 

Artificial Human Milk. — An admirable plan of treating cow's 
milk, so as to reduce it to almost absolute chemical identity with 
human milk, has been devised by Professor Frankland, to whom I 
am indebted for permission to insert the recipe. I have followed this 
method in many cases, and find it far superior to the usual one, as it 
produces an exact and uniform compound. With a little practice 



MANAGEMENT OF THE INFANT, LACTATION, BTC. G01 

nurses can make it with no more trouble than the ordinary mixing oJ 
cow's milk with water and Bugar. The following extract from Dr. 
Frankland's work 1 will explain the principles on which the prepara- 
tion of the artificial human milk is founded : " The rearing of infants 
who cannot be supplied with their natural food is notoriously difficult 
and uncertain, owing chiefly to the great difference in the chemical 
composition of human milk and cow^s milk. The latter is much richer 
in casein and poorer in milk-sugar than the former, whilst ass's milk, 
which is sometimes used for feeding infants, is too poor in casein and 
butter, although the proportion of sugar is nearly the same as in human 
milk. The relations of the three kind- of milk to each other arc clearly 
seen from the following analytical numbers, which express the per- 
centage amounts of the different constituents : 

Woman. Cow. 

sein 2.7 17 4.2 

Butter 1.3 

Milk-sugar 5.0 4.5 

Salts 0.2 0.5 7 

These numbers show that by the removal of one-third of the easein 
from cow'- milk and the addition of about one-third more milk-sugar, 
a liquid is obtained which closely approaches human milk in composi- 
tion, the percentage amounts of the four chief constituents being as 
follow- : 

Casein 2.8 

Butter 

Milk-sugar 5 

Salts 0.7 



The following is the mode of preparing the milk : Allow one-third of 
a pint of new milk to stand for about twelve hours, remove the cream, 
and to the latter add two-thirds of a pint of new milk, as fresh from 
the cow as possible. Into the one-third of a pint of blue milk left 
after the abstraction of the cream put a piece of rennet about one inch 
square. Set the vessel in warm water until the milk is fully curdled. 
an operation requiring from live to fifteen minutes according to the 
activity of the rennet, which should be removed as soon as the curdling 
commences and put into an egg-cup for use on subsequent occasions, 
as it may be employed daily for a month or two. Break up the curd 
repeatedly, and carefully separate the whole of the whey, which should 
then be rapidly heated to boiling in a -mall tin pan placed over a 
spirit or gas lamp. During the heating a further quantity of casein, 
technically called ' Meetings/ separate-, and must be removed by 
straining through muslin. Now dissolve 110 grain- of powdered 
sugar of milk in the hot whey, and mix it with the two-thirds of a 
pint of new milk to which the cream from the other third of a pint 
was added a- already described. The artificial milk should be used 
within twelve hour- of its preparation, and it i- almost needle— to 
add that all the vessels employed in it< manufacture and administra- 
tion should be kept scrupulously clean." 5 

i Franklands Experimental Researches in Chemistry, p. 843. 

- The following recipe yields the same results, but the method is easier, and I find that nurses 
prepare the milk with less difficulty when it is followed : " Heat half a pint of skimmed milk to 
about 96°, that is, just warm, and well stir into the warmed milk a measure full of Walden's 



602 THE PUERPERAL STATE. 

Method of Hand-feeding-. — Much of the success of bottle-feeding 
must depend on minute care and scrupulous cleanliness, points which 
cannot be too strongly insisted on. Particular attention should be 
paid to preparing the food fresh for every meal, and to keeping the 
feeding bottle and tubes constantly in water when not in use, so that 
minute particles of milk may not remain about them and become sour. 
A neglect of this is one of the most fertile sources of the thrush from 
which bottle-fed infants often suffer. The particular form of bottle 
used is not of much consequence. Those now commonly employed, 
with a long India-rubber tube attached, are preferable to the older 
forms of flat bottle, as they necessitate strong suction on the part of 
the infant, thus forcing it to swallow the food more slowly. Care 
must be taken to give the meals at stated periods, as in breast-feeding, 
and these should be at first about two hours apart, the intervals being 
gradually extended. The nurse should be strictly cautioned against 
the common practice of placing the bottle beside the infant in its 
cradle and allowing it to suck to repletion — a practice which leads to 
over-distention of the stomach and consequent dyspepsia. The child 
should be raised in the arms at the proper time, have its food admin- 
istered, and then replaced in the cradle to sleep. In the first few 
weeks of bottle-feeding constipation is very common, and may be 
effectually remedied by placing as much phosphate of soda as will lie 
on a threepenny-piece in the bottle, two or three times in the twenty- 
four hours. 

Other Kinds of Pood. — If this system succeed, no other food should 
be given until the child is six or seven months old, and then some of 
the various infants' foods may be cautiously commenced. Of these 
there are an immense number in common use, some of which are good 
articles of diet, others are unfitted for infants. In selecting them we 
have to see that they contain the essential elements of nutrition in 
proper combination. All those, therefore, that are purely starchy in 
character, such as arrowroot, corn-flour, and the like, should be 
avoided ; while those that contain nitrogenous as well as starch ele- 
ments may be safely given. Of the latter the entire wheat-flour, 
which contains the husks ground down with the wheat, generally 
answers admirably ; and of the same character are rusks, tops and 
bottoms, Xestle's or Liebig's infants' food, and many others. If the 
child be pale and flabby, some more purely animal food may often be 
given twice a day, and great benefit may be derived from a single 
meal of beef, chicken, or veal tea, with a little bread-crumb in it, 
especially after the sixth or seventh month. Milk, however, should 
still form the main article of diet, and should continue to do so for 
many months. 

Management when Milk Disagrees. — If the child be pale, flabby, 
and do not gain flesh, more especially if diarrhoea or other intestinal 
disturbance be present, we may be certain that hand-feeding is not 

extract of rennet. When it is set, break up the curd quite small, and let it stand for ten or fifteen 
minutes, when the curd will sink ; then place the whey in a saucepan and boil quickly. In a third 
of a pint of this whey dissolve a heaped-up teaspoonful of sugar of milk. Vflien quite cold, add two- 
thirds of a pint of new milk and two teaspoonfuls of cream, well stirring the whole together. If 
during the first month the milk is too rich, use rather more than a third of a pint of whey." 



PUERPERAL ECLAMPSIA. 603 

answering satisfactorily, and that some change is required. If the 
child be not too old, and will still take the breast, that is certainly 

the best remedy, but if that be not possible, it is necessary to alter the 
diet. When milk disagree.-, cream, in the proportion of one tablc- 
spoonfnl to three of water, sometimes answers as well. Occasionally 
also Liebig's or Mellin's infants' food, when carefully prepared, ren- 
ders good service. Too often, however, when once diarrhoea or other 
intestinal disturbance has set in, all our efforts may prove unavailing, 
and the health, if not the life, of the infant becomes seriously im- 
perilled. It is not, however, within the scope of this work to treat of 
the disorders of infants at the breast, the proper consideration of 
which requires a large amount of space, and I therefore refrain from 
making any further remarks on the subject. 



CHAPTEE III. 

PUERPERAL ECLAMPSIA. 

Puerperal Eclampsia. — By the term puerperal eclampsia is meant 
a peculiar kind of epileptiform convulsions, which may occur in the 
latter months of pregnancy, or during or after parturition, and it con- 
stitutes one of the most formidable diseases with which the obstetrician 
has to cope. The attack is often so sudden and unexpected, so terrible 
in its nature, and attended with such serious danger both to the 
mother and child, that the disease has attracted much attention. 

Its Doubtful Etiology. — The researches of Lever, Braun, Frerichs, 
and many other writers who have shown the frequent association of 
eclampsia with albuminuria, have of late years been supposed to 
clear up to a great extent the etiology of the disease and to prove its 
dependence on the retention of urinary elements in the blood. ^Vhile 
the urinary origin of eclampsia has been pretty generally accepted, 
more recent observations have tended to throw doubt on its essential 
dependence on this cause ; so that it can hardly be said that we are 
yet in a position to explain its true pathology with certainty. These 
points will require separate discussion, but it is first necessary to 
describe the character and history of the attack. 

Considerable confusion exists in the description of puerperal con- 
vulsions from the confounding of several essentially distinct diseases 
under the same name. Thus in most obstetric works it has been 
customary to describe three distinct classes of convulsion, the epileptic, 
the hysterical, and the apoplectic. The two latter, however, come 
under a totally different category. A pregnant woman may suffer 
from hysterical paroxysms, or she may be attacked with apoplexy 



604 THE PUERPERAL STATE. 

accompanied with coina and followed by paralysis. But these con- 
ditions in the pregnant or parturient woman are identical with the 
same diseases in the non-pregnant, and are in no way special in their 
nature. True eclampsia, however, is different in its clinical history 
from epilepsy, although the paroxysms while they last are essentially 
the same as those of an ordinary epileptic fit. 

Premonitory Symptoms. — An attack of eclampsia seldom occurs 
without haying been preceded by certain more or less well marked 
precursory symptoms. It is true that in a considerable number of 
cases these are so slight as not to attract attention, and suspicion is not 
aroused until the patient is seized with convulsions. Still, subsequent 
investigations will very generally show that some symptoms did exist, 
which, if observed and properly interpreted, might have put the prac- 
titioner on his guard, and possibly have enabled him to ward off the 
attack. Hence a knowledge of them is of real practical value. The 
most common are associated with the cerebrum, such as severe head- 
ache, which is the one most generally observed, and is sometimes 
limited to one side of the head. Transient attacks of dizziness, spots 
before the eyes, loss of sight, or impairment of the intellectual faculties 
are also not uncommon. These signs in a pregnant woman are of the 
gravest import, and should at once call for investigation into the 
nature of the case. Less marked indications sometimes exist in the 
form of irritability, slight headache or stupor, and a geneal feeling of 
indisposition. Another important premonitory sign is oedema of the 
subcutaneous cellular tissue, especially of the face or upper extremities, 
which should at once lead to an examination of the urine. 

Whether such indications have preceded an attack or not, as soon 
as the convulsion comes on there can no longer be any doubt as to the 
nature of the case. The attack is generally sudden in its onset, and 
in its character is precisely that of a severe epileptic fit or of con- 
vulsions in children. Close observation shows that there is at first a 
short period of tonic spasm affecting the entire muscular system. 
This is almost immediately succeeded by violent clonic contractions, 
generally commencing in the muscles of the face, which twitch 
violently ; the expression is horribly altered, the globes of the eyes are 
turned up under the eyelids, so as to leave only the white sclerotics 
visible, and the angles of the mouth are retracted and fixed in a con- 
vulsive grin. The tongue is at the same time protruded forcibly, and, 
if care be not taken, is apt to be lacerated by the violent grinding of 
the teeth. The face, at first pale, soon becomes livid and cyanosed, 
while the veins of the neck are distended, and the carotids beat vigor- 
ously. Frothy saliva collects about the mouth, and the whole appear- 
ance is so changed as to render the patient quite unrecognizable. The 
convulsive movements soon attack the muscles of the body. The hands 
and arms, at first rigidly fixed, with the thumbs clenched into the 
palms, begin to jerk, and the whole muscular system is thrown into 
rapidly recurring convulsive spasms. It is evident that the involun- 
tary muscles are implicated in the convulsive action as well as the 
voluntary. This is shown by a temporary arrest of respiration at 
the commencement of the attack, followed by irregular and hurried 



PUERPERAL ECLAMPSIA. 605 

respiratory movements producing a peculiar hissing sound. The 

occasional involuntary expulsion of urine and feces indicates the 
same fact. During the attack the patient is absolutely unconscious, 
sensibility is totally suspended, and she has afterward no recollection 

of what has taken place. Fortunately the convulsion is not of long 
duration, and at the outside does not last more than three or four 
minutes, generally not so long, and it has been pointed out that a 
longer paroxysm would almost necessarily prove fatal on account of 
the implication of the respiratory muscles. In most cases, after an 
interval there is a recurrence of the convulsion characterized by the 
same phenomena, and the paroxysms are repeated with more or less 
force and frequency according to the severity of the attack. Sometimes 
several hours may elapse before a second convulsion comes on ; at 
others the attacks may recur very often, with only a few minutes 
between them. In the slighter forms of eclampsia there may not be 
more than two or three paroxysms in all ; in the more serious as many 
as fifty or sixty have been recorded. 

Condition between the Attacks. — After the first attack the 
patient generally soon recovers her consciousness, being somewhat 
dazed and somnolent, with no clear conception of what has occurred. 
If the paroxysms be frequently repeated, more or less profound coma 
continues in the intervals between them, which no doubt depends 
upon intense cerebral congestion, resulting from interference with the 
circulation in the great veins of the neck, produced by spasmodic con- 
traction of the muscles. The coma is rarely complete, the patient 
showing signs of sensibility when irritated, and groaning during the 
uterine contractions. In the worst class of cases the torpor may 
become intense and continuous, and in this state the patient may die. 
AVhen the convulsions have entirely stopped, and the patient has com- 
pletely regained her consciousness and is apparently convalescent, 
recollection of what has taken place during and some time before the 
attack may be entirely lost, and this condition may last for a con- 
siderable time. A curious instance of this ouce came under my notice 
in a lady who had lost her brother, to whom she was greatly attached, 
in the week immediately preceding her confinement, and in whom the 
mental distress seemed to have had a great deal to do in determining 
the attack. It was many weeks before she recovered her memory, 
and during that time she recollected nothing about the circumstances 
connected witli her brother's death, the wdiole of that week being, as 
it were, blotted out of her recollection. 

Relation of the Attacks to Labor. — If the convulsions come on 
during pregnancy, we may look upon the advent of labor as almost a 
certainty; and if we consider the severe nervous shock and general 
disturbance, this is the result we might reasonably anticipate. If they 
occur, as is not uncommon, for the first time during labor, the pains 
generally continue with increased force and frequency, since the uterus 
partakes of the convulsive action. It has not rarely happened that 
the pains have gone on with such intensity that the child has been 
born quite unexpectedly, the attention of the practitioner being taken 
up with the patient. In many cases the advent of fresh paroxysms is 



606 THE PUERPERAL STATE. 

associated with the commencement of a pain, the irritation of which 
seems sufficient to bring on the convulsion. 

Results to the Mother and Child. — The results of eclampsia vary 
according to the severity of the paroxysms. It is generally said that 
about one in three or four cases dies. The mortality has certainly 
lessened of late years, probably in consequence of improved knowledge 
of the nature of the disease and more rational modes of treatment. 
This is well shown by Barker, 1 who found in 1885 a mortality of 32 
per cent, in cases occurring before and during labor, and 22 per cent, 
in those after labor ; while since that date the mortality has fallen to 
14 per cent. The same conclusion is arrived at by Dr. Phillips, 2 who 
has shown that the mortality has greatly lessened since the practice of 
repeated and indiscriminate bleeding, long considered the sheet-anchor 
in the disease, has been discontinued and the administration of chloro- 
form substituted. 

Cause of Death. — Death may occur during the paroxysm, and then 
it may be due to the long continuance of the tonic spasm producing 
asphyxia. It is certain that, as long as the tonic spasm lasts, the 
respiration is suspended, just as in the disease of children known 
as laryngismus stridulus ; and it is possible also that the heart may 
share in the convulsive contraction which is known to affect other 
involuntary muscles. More frequently, death happens at a later period 
from the combined effects of exhaustion and asphyxia. The records of 
post-mortem examinations are not numerous ; in those we possess, the 
principal changes have been an anaemic condition of the brain, with 
some cedematous infiltration. In a few rare cases the convulsions have 
resulted in effusion of blood into the ventricles, or at the base of the 
brain. The prognosis as regards the child is also serious. Out of 
thirty-six children, Hall Davis found twenty-six born alive, ten being 
stillborn. There is good reason to believe that the convulsion may 
attack the child in utero — of this several examples are mentioned by 
Cazeaux ; or it may be subsequently attacked with convulsions, even 
when apparently healthy at birth. 

Pathology. — The precise pathology of eclampsia cannot be con- 
sidered by any means satisfactorily settled. When, in the year 1843, 
Lever first showed that the urine in patients suffering from puerperal 
convulsions was generally highly charged with albumin — a fact which 
subsequent experience has amply conhrrned — it was thought that a key 
to the etiology of the disease had been found. It was known that 
chronic forms of Brigkt's disease were frequently associated with reten- 
tion of urinary elements in the blood, and not rarely accompanied by 
convulsions. The natural inference was drawn that the convulsions of 
eclampsia were also due to toxaemia resulting from the retention of 
urea in the blood, just as in the uraemia of chronic Blight's disease ; 
and this view was adopted and supported by the authority of Braun. 
Frerichs. and many other writers of eminence, and was pretty generally 
received as a satisfactory explanation of the facts. Frerichs modified 
it so far that he held that the true toxic element was not urea as such, 

1 The Puerperal Diseases, p. 125. - Guy"s Hospital Reports, 1870. 



PUERPERAL ECLAMPSIA. 607 

but carbonate of ammonia, resulting from its decomposition ; and ex- 
periments were made to prove that the injection of this substance into 
the veins of the lower animals produced convulsions of precisely the 
same character as eclampsia. Dr. Hammond, 1 of Maryland, subse- 
quently made a series of counter-experiments which were held as 
proving that there was no reason to believe that urea ever did become 
decomposed in the blood in the way that Frcrichs supposed, or that the 
symptoms of uraemia were ever produced in this way. Others have 
believed that the poisonous elements retained in the blood are not urea 
or the products of its decomposition, but other extractive matters 
which have escaped detection. As time elapsed, evidence accumulated 
to show that the relation between albuminuria and eclampsia was not 
so universal as was supposed, or at least that some other factors were 
necessary to explain many of the cases. Numerous cases were observed 
in which albumin was detected in large quantities, without any con- 
vulsion following, and that not only in women who had been subject 
to B right's disease before conception, but also when the albumin- 
uria was known to have developed during pregnancy. Thus Imbert 
Goubeyre found that out of 164 cases of the latter kind, 95 had no 
eclampsia ; and Blot, out of 41 cases, found that 34 were delivered 
without untoward symptoms. It may be taken as proved, therefore, 
that albuminuria is by no means necessarily accompanied by eclampsia, 
Cases were also observed in which the albumin only appeared after the 
convulsion ; and in these it was evident that the retention of urinary 
elements could not have been the cause of the attack ; and it is highly 
probable that in them the albuminuria was produced by the same cause 
which induced the convulsion. Special attention has been called to 
this class of cases by Braxton Hicks, 2 who has recorded a considerable 
number of them. He says that the nearly simultaneous appearance of 
albuminuria and convulsion — and it is admitted that the two are almost 
invariably combined — must then be explained in one of three ways : 

1. That the convulsions are the cause of the nephritis. 

2. That the convulsions and the nephritis are produced by the same 
cause, e. g., some detrimental ingredient circulating in the blood, irri- 
tating both the cerebro-spinal system and other organs at the same 
time. 

3. That the highly congested state of the venous system induced by 
the spasm of the glottis in eclampsia is able to produce the kidney 
complication. 

More recently Traube and Rosenstein have advanced a theory of 
eclampsia purporting to explain these anomalies. They refer the 
occurrence of eclampsia to acute cerebral anamiia resulting from 
changes in the blood incident to pregnancy. The primary factor is 
the hydraemie condition of the blood, which is an ordinary concomitant 
of pregnancy, and, of course, when there is also albuminuria, the 
watery condition of the blood is greatly intensified ; hence the frequent 
association of the two states. Accompanying this condition of the 
blood, there is increased tension of the arterial system, which is 

i Amer. Journ. of Med. Sciences, 1861. 2 Obst. Trans., 1867, vol. viii. \>. 823. 



608 THE PUERPERAL STATE. 

favored by the hypertrophy of the heart which is known to be a nor- 
mal occurrence in pregnancy. The result of these combined states is 
a temporary hyperemia of the brain, which is rapidly succeeded by 
serous effusion into the cerebral tissues, resulting in pressure on its 
minute vessels and consequent anaemia. There is much in this theory 
that accords with the most recent views as to the etiology of convulsive 
disease ; as, for example, the researches of Kussmaul and Tenner, who 
had experimentally proved the dependence of convulsions on cerebral 
anaemia, and of Brown-Sequard, who showed that an anaemic condition 
of the nerve-centres preceded an epileptic attack. It explains also 
very satisfactorily how the occurrence of labor should intensify the 
convulsions, since, during the acme of the pains, the tension of the 
cerebral arterial system is necessarily greatly increased. There are, 
however, obvious difficulties against its general acceptance. For ex- 
ample, it does not satisfactorily account for those cases which are 
preceded by well-marked precursory symptoms, and in which an 
abundance of albumin is present in the urine. Here the premonitory 
signs are precisely those which precede the development of uraemia in 
chronic Bright's disease, the dependence of which on the retention in 
the blood of urinary elements can hardly be doubted. Moreover, it 
has been shown by Lohlein and others that on post-mortem examination 
the brain does not, as a rule, exhibit the oedema, anaemia, and flattened 
convolutions which this theory assumes. 

MacDonald 1 has published an interesting paper on this subject, in 
which he describes two very careful post-mortem examinations. In 
these he found extreme anaemia of the cerebro-spinal centres, with 
congestion of the meninges, but no evidence of oedema. He inclines 
to the belief that eclampsia is caused by irritation of the vasomotor 
centre in consequence of an anaemic condition of the blood produced 
by the retention in it of excrementitious matters which the kidneys 
ought to have removed, this over-stimulation resulting in anaemia of 
the deeper-seated nerve-centres and consequent convulsion. 

Excitability of the Nervous System in Puerperal "Women as 
Predisposing" to Convulsions. — The key to the liability of the puer- 
pera to convulsive attacks is no doubt to be found in the peculiarly 
excitable condition of the nervous system in pregnancy — a fact which 
was clearly pointed out by the late Dr. Tyler Smith and by many 
other Avriters. Her nervous system is, in this respect, not unlike that 
of children, in whom the predominant influence aud great excitability 
of the nervous system are well-established facts, and in whom precisely 
similar convulsive seizures are of common occurrence on the applica- 
tion of a sufficiently exciting cause. 

Exciting- Causes. — Admitting this, we require some cause to set 
the predisposed nervous system into morbid action, and this we may 
have either in the toxaemic or in an extremely watery condition of 
the blood, associated with albuminuria ; or along with these, or some- 
times independently of them, in some excitement, such as strong emo- 
tional disturbance. It is highly probable, however, that extreme 

1 See his volume of collected essays, entitled Heart Disease during Pregnancy. London, 187S. 






PUERPERAL ECLAMPSIA. 609 

anaemia is one of the actual conditions of the nerve-centres — a fad of 

much practical importance in reference to treatment. 

Treatment. — The management of cases in which the occurrence of 

suspicious symptoms has led to the detection of albuminuria lias 
already been fully discussed (p. 215). We shall therefore, here, only 

consider the treatment of eases in which convulsions have actually 
occurred. 

Uutil quite recently venesection was regarded as the sheet-anchor 
in the treatment, and blood was always removed copiously, and, there 
is sufficient reason to believe, with occasional remarkable benefit. 
Many cases are recorded in which a patient, in apparently profound 
coma, rapidly regained her consciousness when blood was extracted in 
sufficient quantity. The improvement, however, was often transient, 
the convulsions subsequently recurring with increased vigor. There 
are good theoretical grounds for believing that bloodletting can only 
be of merely temporary use, and may even increase the tendency to 
convulsion. These are so well put by Schroeder, that I cannot do 
better than quote his observations on this point : " If," he says, " the 
theory of Traube and Rosenstein be correct, a sudden depletion of the 
vascular system, by which the pressure is diminished, must stop the 
attacks. From experience it is known that after venesection the quan- 
tity of blood soon becomes the same through the serum taken from all 
the tissues, while the quality is greatly deteriorated by the abstraction 
of blood. A short time after venesection we shall expect to find 
the former blood-pressure in the arterial system, but the blood far 
more watery than previously. From this theoretical consideration, 
it follows that abstraction of blood, if the above-mentioned conditions 
really cause convulsions, must be attended by an immediate favorable 
result, and, under certain circumstances, the whole disease may surely 
be cut short by it. But, if all other conditions remain the same, the 
blood-pressure will after some time again reach its former height. 
The quality of blood has in the meantime been greatly deteriorated, 
and consequently the danger of the disease will be increased." 

These views sufficiently well explain the varying opinions held with 
regard to this remedy, and enable us to understand why, while the 
effects of venesection have been so lauded by certain authors, the mor- 
tality has admittedly been much lessened since its indiscriminate use 
has been abandoned. It does not follow because a remedy, when 
carried to excess, is apt to be hurtful that it should be discarded 
altogether ; and I have no doubt that in properly selected cases and 
judiciously employed, venesection is a valuable aid in the treatment of 
eclampsia, and that it is specially likely to be useful in mitigating the 
first violence of the attack and in giving time for other remedies to 
come into action. Care should, however, be taken to select the cases 
properly, and it will be specially indicated when there is marked 
evidence of great cerebral congestion and vascular tension, such as a 
livid face, a full bounding pulse, and strong pulsation in the carotids. 
The general constitution of the patient may also serve as a guide in 
determining its use, and we shall be the more disposed to resort to it 
if the patient be a strong and healthy woman ; while on the other 

39 



610 THE PUERPERAL STATE. 

hand, if she be feeble and weak, we may wisely discard it and trust 
entirely to other means. In any case it must be looked upon as a 
temporary expedient only, useful in warding off immediate danger to 
the cerebral tissues, but never as the main agent in treatment. Xor 
can it be permissible to bleed in the heroic manner frequently recom- 
mended. A single bleeding, the amount regulated by the effect 
produced, is all that is ever likely to be of service. 

As a temporary expedient, having the same object in view, com- 
pression of the carotids during the paroxysms is worthy of trial. This 
was proposed by Trousseau in the eclampsia of infants, and in the 
single case of eclampsia in which I have tried it, it seemed decidedly 
beneficial. It is simple, and it offers the advantage of not leading 
to any permanent deterioration of the blood, as in venesection. 

As a subsidiary means of diminishing vascular tension the admin- 
istration of a strong purgative is desirable, and has the further effect 
of removing any irritant matter that may be lodged in the intestinal 
tract. If the patient be conscious, a full dose of the compound jalap 
powder may be given, or a few grains of calomel combined with jalap ; 
if comatose and unable to swallow, a drop of croton oil or a quarter 
of a grain of elaterium may be placed on the back of the tongue. 

The great indication in the management of eclampsia is the con- 
trolling of convulsive action bv means of sedatives. Foremost amongst 
them must be placed the inhalation of chloroform, a remedy which is 
frequently remarkably useful, and which has the advantage of being 
applicable at all stages of the disease, and whether the patient be 
comatose or not. Theoretical objections have been raised against its 
employment, as being likely to increase cerebral congestion : of this 
there is no satisfactory proof; on the contrary there is reason to think 
that chloroform inhalation has rather the effect of lessening arterial 
tension, while it certainly controls the violent muscular action by 
which the hyperemia is so much increased. Practically no one who 
has used it can doubt its great value in diminishing the force and 
frequency of the convulsive paroxysms. Statistically its usefulness is 
shown by Charpentier in his thesis on the effects of various methods 
of treatment in eclampsia, since out of sixty-three cases in which it 
was used, in forty-eight it had the effect of diminishing or arresting 
the attacks, one only proving fatal. The mode of administration has 
varied. Some have given it almost continuously, keeping the patient 
in a more or less profound state of anaesthesia. Others have contented 
themselves with carefully watching the patient, and exhibiting the 
chloroform as soon as there were any indications of a recurring 
paroxysm, with the view of controlling its intensity. The latter is 
the plan I have myself adopted, and of the value of which in most 
cases I have no doubt. Every now and again cases will occur in 
which chloroform inhalation is insufficient to control the paroxysm, or 
in which, from the very cyanosed state of the patient, its administra- 
tion seems contra-indicated. Moreover, it is advisable to have, if 
possible, some remedy more continuous in its action and requiring 
less constant personal supervision. Latterly the internal administra- 
tion of chloral has been recommended for this purpose. My own 



PUERPERAL ECLAMPSIA. 611 

experience is decidedly in its favor, and I bave used, with, as I believe, 
marked advantage, a combination of chloral with bromide of potassium, 
in the proportion of twenty grains of the former to half a drachm of 
the latter, repeated at intervals of from four to six hours. If the 
patient he unable to swallow, the chloral may he given in an enema 
or hypodermically, six grains being diluted in .Ij of water, and injected 
under the skin. The remarkable influence of bromide of potassium 
iu controlling the eclampsia of infants would seem to be an indication 
for its use in puerperal eases. Fordvce Barker was opposed to the use 
of chloral, which he thought excited instead of lessening reflex irrita- 
bility. 1 Another remedy, not entirely free from theoretical objections, 
but strongly recommended, is the subcutaneous injection of morphia, 
which has the advantage of being applicable when the patient is quite 
unable to swallow. It may be given in doses of one-third of a grain, 
repeated in a few hours, so as to keep the patient well under its influ- 
ence. It is to be remembered that the object is to control muscular 
action, so as to prevent as much as possible the violent convulsive 
paroxysm, and, therefore, it is necessary that the narcosis, however pro- 
duced, should be continuous. It is rational, therefore, to combine the 
intermittent action of chloroform with the more continuous action of 
other remedies, so that the former should supplement the latter when 
insufficient. Inhalation of the nitrite of amyl has been recommended 
on physiological grounds as likely to be useful, and is well worthy of 
trial ; but of its action I have, as yet, no personal experience. Several 
very successful cases of treatment by the inhalation of oxygen have 
been recorded by Schmidt, of St. Petersburg. 2 Pilocarpine has recently 
been tried, in the hope that the diaphoresis and salivation it produces 
might diminish arterial tension and free the blood of toxic matters. 
Braun 3 administered three centigrammes of the muriate of pilocarpine 
hypodermically, and reports favorably of the result ; Fordvce Barker, 4 
however, was of opinion that it produced so much depression as to be 
dangerous. 

Other remedies, supposed to act in tUe way of antidotes to nrsemic 
poisoning, have been advised, such as acetic or benzoic acid, but they 
are far too uncertain to have any reliance placed on them, and they 
distract attention from more useful measures. 

Precautions during- the Paroxysm. — Precautions are necessary 
during the fits to prevent the patient injuring herself, especially to 
obviate laceration of the tongue ; the latter can be best done by placing 
something between the teeth as the paroxysm comes on, such as the 
handle of a teaspoon enveloped in several folds of flannel. 

Obstetric Management. — The obstetric management of eclampsia 
will naturally give rise to much anxiety, and on this point there has 
been considerable difference of opinion. On the one hand, we have 
practitioners who advise the immediate emptying of the uterus, even 
when labor has commenced ; on the other, those who would leave the 
labor entirely alone. Thus Gooch said : " Attend to the convulsions, 

1 The Puerperal Diseases, p. 120. 

2 London Med. Record, 188(5, vol. xiv. p. 75. (Extr. from Russkaia Meditz., 1885, No. 32, p. 595.) 
s Berl. klin. Wochenschr., June 16, 1879. * New York Med. Record, March 1, 1879. 



612 THE PUERPERAL STATE. 

and leave the labor to take care of itself;" and Scliroeder said : " Espe- 
cially no kind of obstetric manipulation is required for the safety of 
the mother/' but he admitted that it is sometimes advisable to hasten 
the labor to insure the safety of the child. 

In cases in which the convulsions come on during labor, the pains 
are often strong and regular, the labor progresses satisfactorily, and 
no interference is needful. In others we cannot but feel that empty- 
ing the uterus would be decidedly beneficial. TTe have to reflect, 
however, that any active interference might, of itself, prove very 
irritating and excite fresh attacks. The influence of uterine irritation 
is apparent by the frequency with which the paroxysms recur with 
the pains. If, therefore, the os be undilated and labor have not 
begun, no active means to induce it should be adopted, although the 
membraues may be ruptured with advantage, since that procedure 
produces no irritation. Forcible dilatation of the os, and especially 
turning, are strongly contra-indicated. 

The rule laid down by Tyler Smith seems that which is most 
advisable to follow — that we should adopt the course which seems 
least likely to prove a source of irritation to the mother. Thus, if 
the fits seem evidently induced and kept up by the pressure of the 
foetus, and the head be within reach, the forceps may be resorted to. 
But if, on the other hand, there be reason to think that the operation 
necessary to complete delivery is likely per se to prove a greater 
source of irritation than leaving the case to Nature, then we should 
not interfere. 

[If called to a case of convulsions followed by coma in a primipara 
near term, but not in labor, draw off a little urine and examine it, as 
the patient may be far advanced in Bright's disease and the coma 
purely uraemic. In such a case little can be gained by bringing on 
labor and delivering the foetus. 

Eclampsia is sometimes purely reflex, and not at all dangerous, 
although it may be alarming. The convulsive movements may arise 
from nerve-disturbance due to the foetal head distending the cervix in 
the last stage of dilatation in primipara?. AVhen the head begins to 
distend the perineum the convulsive seizure often ceases. Such patients 
are safer without the forceps. — Ed.] 



CHAPTEK IV. 

PUERPERAL INSANITY. 

Classification. — Under the head of " Puerperal Mania/' writers on 
obstetrics have indiscriminately classed all cases of mental disease 
connected with pregnancy and parturition. The result has been unfor- 
tunate, for the distinction between the various types of mental disorder 



PUERPERAL INSANITY. 613 

lias, in consequence, been very generally lost sight of. But little study 
of the subject suffices to show that the term puerperal mania is wrong 
in more ways than one, for we find that a large number of cases are 
not eases of " mania 1 ' at all, but of melancholia ; while a. considerable 
number are not, strictly speaking, " puerperal," as they either come 
on during pregnancy, or long after the immediate risks of the puerperal 
period are over, being in the latter ease associated with anaemia pro- 
duced by over-lactation. For the sake of brevity the generic term, 
" puerperal insanity," may be employed to cover all cases of mental 
disorders connected with gestation, which may be further conveniently 
subdivided into three classes, each having its special characteristics, 
viz. : 

I. The insanity of 'pregnancy. 
II. Puerperal insanity, properly so called ; that is, insanity coming 
on within a limited period after delivery. 
III. The insanity of lactation. 

This division is a strictly natural one, and includes all the cases 
likely to come under observation. The relative proportion these 
classes bear to each other can only be determined by accurate statistical 
observations on a large scale, but these materials we do not possess. 
The returns from large asylums are obviously open to objection, for 
only the worst and most confirmed cases find their way into these 
institutions, while by far the greater proportion, both before and after 
labor, are treated in their own homes. 

Proportion of these forms of insanity. Taking such returns 
as only approximate, we find from Dr. Batty Tuke 1 that in the Edin- 
burgh Asylum, out of 155 cases of puerperal insanity, 28 occurred 
before delivery, 73 during the puerperal period, and 54 during lacta- 
tion. The relative proportions of each per hundred are as follows : 

Insanity of pregnancy 18.06 per cent. 

Puerperal insanity 47.09 " 

Insanity of lactation 34.83 " 



Marce 2 collects together several series of cases from various authorities, 
amounting to 310 in all, and the results are not very different from 
those of the Edinburgh Asylum, except in the relatively smaller 
number of cases occurring before delivery. The percentage is calcu- 
lated from his figures : 

Insanity of pregnancy 8.06 per cent. 

Puerperal insanity 58.06 " 

Insanity of lactation ... 30.30 " 

As each of these classes differs in various important respects from the 
others, it will be better to consider each separately. 

The Insanity of Pregnancy is, without doubt, the least common 
of the three forms. The intense mental depression which in many 
women accompanies pregnancy, and causes the patient to take a 
despondent view of her condition, and to look forward to the result 
of her labor with the most gloomy apprehension, seems to be often 

1 Edin. Med. Journ., vol. x. 2 Traite de la Folie des Femraes enceintes. 



614 THE PUEKPEKAL STATE. 

onlv a lesser degree of the actual mental derangement which is occa- 
sionally met with. The relation between the two states is further 
borne out by the fact that a large majority of cases of insanity during 
pregnancy are well-marked types of melancholia; out of 28 cases 
recorded by Tuke, 15 were examples of pure melancholia, and 5 of 
dementia with melancholia. In many of these the attack could be 
traced as developing itself out of the ordmary hypochondriasis of 
pregnancy. In others the symptoms came on at a later period of 
pregnancy, the earlier months of which had not been marked by any 
unusual lowness of spirits. The age of the patient seems to have 
some influence, the proportion of cases between thirty and forty years 
of age being much larger than in younger women. A larger propor- 
tion of cases occurs in primiparae than in multipara?, a fact that no 
doubt depends on the greater dread and apprehension experienced by 
women who are pregnant for the first time, especially if not very 
voung. Hereditary disposition plays an important part, as in all 
forms of puerperal insanity. It is not always easy to ascertain the 
fact of an hereditary taint, since it is often studiously concealed by 
the friends. Tuke, however, found distinct evidence of it in no less 
than 12 out of 28 cases. Furstner 1 believes that other neuroses have 
an importaut influence in the production of the disease. Out of 32 
cases he found direct hereditary taint in 9, but in 11 more there was 
a family history of epilepsy, drunkenness, or hysteria. 

Period of pregnancy at which it occurs. The period of preg- 
nancy at which mental derangement most commonly shows itself 
varies. Most generally, perhaps, it is at the end of the third or the 
beginning of the fourth month. It may, however, begin with con- 
ception, and even return with every impregnation. Montgomery 
relates an instance in which it recurred in three successive pregnan- 
cies. Marce distinguishes between true insanity coming on during 
pregnancy aud aggravated hypochondriasis, by the fact that the latter 
usually lessens after the third month, while the former most com- 
monly begins after that date. It is unquestionable that in many cases 
no such distinction can be made, and that the two are often very inti- 
mately associated. 

The form of insanity does not differ from ordmary melancholia. 
The suicidal tendency is generally very strongly developed. Should 
the mental disorder continue after delivery, the patient may very 
probably experience a strong impulse to kill her child. Moral per- 
versions have not been uncommonly observed. Tuke especially men- 
tions a tendency to dipsomania in the early months, even in women 
who have not shown any disposition to excess at other times. He 
suggests that this may be an exaggeration of the depraved appetite or 
morbid craving so commonly observed in pregnant women, just as 
melancholia may be a further development of lowness of spirits. 
Laycock mentions a disposition to "kleptomania" as very character- 
istic of the disease. Casper 2 relates a curious case where this occurred 
in a pregnant lady of rank, and the influence of pregnancy in devel- 

1 Archiv fur Psychiatrie, Band v. Heft 2. 

2 Casper's Forensic Medicine, Xew Syd. Soc, vol. iv. p. 30S. 



PUERPERAL INSANITY. 615 

oping an irresistible tendency was pleaded in a criminal trial in which 
one of her petty thefts had involved her. 

The prognosis may be said to be, on the whole, favorable. Out of 
Dr. Tuke's twenty-eight cases, nineteen recovered within six months. 
There is little hope of a cure until after the termination of the preg- 
nancy, as out of nineteen cases recorded by Marco, in only two did 
the insanity disappear before delivery. 

Transient Mania during- Delivery. — There is a peculiar form of 
mental derangement sometimes observed during labor, which is by 
some talked of as a temporary insanity. It may, perhaps, be more 
accurately described as a kind of acute delirium, produced, in the 
latter stage of labor, by the intensity of the suffering caused by the 
pains. According to Montgomery, it is most apt to occur as the head 
is passing through the os uteri, or at a later period, during the expul- 
sion of the child. It may consist of merely a loss of control over the 
mind, during which the patient, unless carefully watched, might, in her 
agony, seriously injure herself or her child. Sometimes it produces 
actual hallucination, as in the case described by Tarnier, in which the 
patient fancied she saw a spectre standing at the foot of her bed, 
which she made violent effort to drive away. This kind of mania, if 
it may be so called, is merely transitory in its character, and disap- 
pears as soou as the labor is over. From a medico-legal point of view r 
it may be of importance, as it has been held by some that in certain 
cases of infanticide the mother has destroyed the child when in this 
state of transient frenzy, and when she was irresponsible for her acts. 
In the treatment of this variety of delirium we must, of course, try 
to lessen the intensity of the suffering, and it is in such cases that 
chloroform will find one of its most valuable applications. 

True Puerperal Insanity has always attracted much attention from 
obstetricians, often to the exclusion of other forms of mental disturb- 
ance connected with the puerperal state. We may define it to be that 
form of insanity which comes on within a limited period after delivery, 
and which is probably intimately connected with that process. Out 
of seventy-three examples of the disease tabulated by Dr. Tuke, only 
two came on later than a month after delivery, and in these there were 
other causes present, which might possibly remove them from this 
class. 

Although a large number of these cases assume the character of 
acute mania, that is by no means the only kind of insanity which is 
observed, a not inconsiderable number being well-marked examples of 
melancholia. The distinction between them was long ago pointed out 
by Gooch, whose admirable monograph on the disease contains one ot 
the most graphic and accurate accounts of puerperal insanity that has 
yet been written. 

There are also some peculiarities as to the period at which these 
varieties of insanity show themselves, which, taken in connection with 
certain facts in their etiology, may eventually justify us in drawing a 
stronger line of demarcation between them than has been usual. It 
appears that cases of acute mania are apt to come on at a period much 
nearer delivery than melancholia. Thus Tuke found that all the 



616 THE PUERPERAL STATE. 

cases of mania came on within sixteen days after delivery, and that all 
cases of melanchola developed themselves after that period. We 
shall presently see that one of the most recent theories as to the cause 
of the disease attributes it to some morbid condition of the blood. 
Should further investigation confirm this supposition, inasmuch as 
septic conditions of the blood are most likely to occur a short time 
after labor, it would not be an improbable hypothesis that cases of 
acute mania, occurring within a short time after labor, may depend on 
such septic causes, while melancholia is more likely to arise from 
general conditions favoring the development of mental disease. This 
must, however, be regarded as a mere speculation, requiring further 
investigation. 

Causes. — Hereditary predisposition is very frequently met with, 
and a careful inquiry into the patient's history will generally show 
that other members of the family have suffered from mental derange- 
ment. Keid found that out of 111 cases in Bethlehem Hospital, there 
was clear evidence of hereditary taint in 45. Tuke made the same 
observation in 22 out of his 73 cases ; and, indeed, it is pretty gen- 
erally admitted by all alienist physicians that hereditary tendencies 
form one of the strongest predisposing causes of mental disturbance 
in the puerperal state. In a large proportion of cases circumstances 
producing debility and exhaustion, or mental depression, have pre- 
ceded the attack. Thus it is often found that patients attacked with 
it have had post-partum hemorrhage or have suffered from some other 
conditions producing exhaustion, such as severe and complicated labor; 
or they may have been weakened by over-frequent pregnancies, or by 
lactation during the early months of pregnancy. Indeed, anaemia is 
always well marked in this disease. Mental conditions also are fre- 
quently traceable in connection with its production. Morbid dread 
during pregnancy, insufficient to produce insanity before delivery, 
may develop into mental derangement after it. Shame and fear of 
exposure in unmarried women not unfrequently lead to it, as is evi- 
denced by the fact that out of 2281 cases gathered from the reports 
of various asylums, above 64 per cent, were unmarried. 1 Sudden 
moral shocks or vivid mental impressions may be the determining 
cause in predisposed persons. Gooch narrated an example of this in 
a lady who was attacked immediately after a fright produced by a fire 
close to her house, the hallucinations in this case being all connected 
with light; and Tyler Smith that of another whose illness dated from 
the sudden death of a relative. The age of the patient has some 
influence, and there seems to be a decidedly greater liability at 
advanced ages, especially when such women are pregnant for the first 
time. 

The possibility of the acute form of puerperal insanity coming on 
shortly after delivery being dependent on some form of septicaemia, is 
one which deserves careful consideration. The idea originated with 
Sir James Simpson, who found albumin in the urine of four patients. 
He suggested that this might probably indicate the presence in the 

1 Journ. of Mental Science, 1870-71, p. 159. 



PUERPERAL INSANITY. 617 

blood oi* certain urinary constituents which might have determined 
the attack much in the same way as in eclampsia. Dr. Donkin sub- 
sequently wrote an important paper, 1 in which he warmly supported 
this theory, and arrived at the conclusion "thai the acute dangerous 
class of cases are examples of ursemic blood-poisoning, of which the 
mania, rapid pulse, and other constitutional symptoms arc merely the 
phenomena;" and that the affection, therefore, ought to be termed 
ursemic or renal puerperal mania, in contradistinction to the other 
form of disease. He also suggests that the immediate poison may 
be carbonate^ of ammonia, resulting from the decomposition of urea 
retained in the blood. It will be observed, therefore, that the patho- 
logical condition producing puerperal mania would, supposing this 
theory to be correct, be precisely the same as that which at other 
times is supposed to give rise to puerperal eclampsia. There can be 
no donbt that the patient, immediately after delivery, is in a condition 
rendering her peculiarly liable to various forms of septic disease ; and 
it must be admitted that there is no inherent improbability in the sup- 
position that some morbid material circulating in the blood may be 
the effective cause of the attack in a person otherwise predisposed to 
it. It is also certain, as I have already pointed out, that there are 
two distinct classes of cases, differing according to the period after 
delivery at which the attack comes on. Whether this difference 
depends on the presence in the blood of some septic matter — especially 
urinary excreta — is a question which our knowledge by no means 
justifies us in answering; it is, however, one which well merits further 
careful study. 

It is only fair to point out some difficulties which appear to militate 
against the view which Dr. Donkin maintains. In the first place, the 
albuminuria is merely transient, while its supposed effects last for 
weeks or months. Sir James Simpson said, with regard to his cases : 
" I have seen all traces of albuminuria in puerperal insanity disappear 
from the urine within fifty hours of the access of the malady. The 
general rapidity of its disappearance is, perhaps, the principal or, 
indeed, the only reason why this complication has escaped the notice 
of those physicians among us who devote themselves with such ardor 
and zeal to the treatment of insanity in our public asylums." This 
apparent anomaly Simpson attempted to explain by the hypothesis 
that, when once the uraemic poisoning has done its work and set the 
disease in progress, the mania progresses of itself. This, however, is 
pure speculation ; and, in the supposed analogous case of eclampsia, 
the albuminuria certainly lasts as long as its effects. It is not easy to 
understand, also, why unemic poisoning should in one case give rise 
to insanity and in another to convulsions. For all we know to the 
contrary, transient albuminuria may be much more common after 
delivery than has been generally supposed, and further investigation on 
this point is required. Albumin is by no means unfrequently observed 
in the urine for a short time in various conditions of the body, with- 
out any serious consequences, as, for example, after bathing ; and we 

1 Edin. Med. Journ., vol. vii. 



618 THE PUERPERAL STATE. 

may too readily draw an unjustifiable conclusion from its detection in 
a few cases of mania. There are, however, many other kinds of blood- 
poisoning besides uraemia which may have an influence in the produc- 
tion of the disease, and it is to be hoped that future observations may 
enable us to speak with more certainty on this point. 

The prognosis of puerperal insanity is a point which will always 
deeply interest those who have to deal with so distressing a malady. 
It may resolve itself into a consideration of the immediate risk to life 
and of the chances of ultimate restoration of the mental faculties. It 
is an old aphorism of Gooch's, and one the correctness of which is jus- 
tified by modern experience, that " mania is more dangerous to life, 
melancholia to reason." It has very generally been supposed that the 
immediate risk to life in puerperal mania is not great, and on the whole 
this may be taken as correct, Tuke found that death took place, from 
all causes, in 10.9 per cent, of the cases under observation; these, how- 
ever, were all women who had been admitted into asylums and in 
whom the attack may be assumed to have been exceptionally severe. 
Great stress was laid by Hunter and Gooch on extreme rapidity of the 
pulse as indicating a fatal tendency. There can be no doubt that it is 
a symptom of great gravity, but by no means one which need lead us 
to despair of our patient's recovery. The most dangerous class of cases 
are those attended with some inflammatory complication ; and if there 
be marked elevation of temperature, indicating the presence of some 
such concomitant state, our prognosis must be more grave than Avhen 
there is mere excitement of the circulation. 

Post-mortem signs. There are no marked post-mortem signs 
found in fatal cases to guide us in forming an opinion as to the nature 
of the disease. a No constant morbid changes," says Tyler Smith, "are 
found within the head, and most frequently the only condition found 
in the brain is that of unusual paleness and exsanguinity. Many 
pathologists have also remarked upon the extremely empty condition 
of the bloodvessels, particularly the veins. 

The duration of the disease varies considerably. Generally speak- 
ing, cases of mania do not last so long as melancholia, and recovery 
takes place within a period of three months, often earlier. Very few 
of the cases admitted into the Edinburgh Asylum remained there more 
than six months, and after that time the chances of ultimate recovery 
greatly lessened. When the patient gets well it often happens that her 
recollection of the events occurring during her illness is lost ; at other 
times the delusions from which she suffered remain, as, for example, 
in a case which was under my care, in which the personal antipathies 
which the patient formed when insane became permanently established. 

Insanity of Lactation. — Fifty-four out of the 155 cases collected 
by Dr. Tuke were examples of the insanity of lactation, which would 
appear, therefore, to be nearly twice as common as that of pregnancy, 
but considerably less so than the true puerperal form. Its dependence 
on causes producing anaemia and exhaustion is obvious and well 
marked. In the large majority of cases it occurs in multipara who 
have been debilitated by frequent pregnancies and by length of nurs- 
ing. When occurring in primiparae it is generally in women who 



PUERPERAL INSANITY. 619 

have suffered from post-partum hemorrhage or other causes oi exhaus- 
tion, or whose constitution was such as should have contra-indicated 
any attempt at lactation. The "bruit do diable" is almost invariably 
present in the veins of the neck, indicating the impoverished condition 
of the Mood. 

'The type is far more frequently melancholic than maniacal, and 
when the latter form occurs, the attack is much more transient than in 
true puerperal insanity. The danger to life is not great, especially if 
the cause producing debility be recgnized and at once removed. 

There seems, however, to be more risk of the insanity becoming 
permanent than in the other forms. In twelve out of Dr. Tuke's cases 
the melancholia degenerated into dementia and the patients became 
hopelessly insane. 

Symptoms. — The symptoms of these various forms of insanity are 
practically the same as in the non-pregnant state. 

Generally in cases of mania there is more or less premonitory indi- 
cation of mental disturbance, which may pass unperceived. The attack 
is often preceded by restlessness and loss of sleep, the latter being a 
very common and well-marked symptom ; or if the patient does sleep, 
her rest is broken and disturbed by dreams. Causeless dislikes to 
those around her are often observed ; the nurse, the husband, the 
doctor, or the child, becomes the object of suspicion, and unless proper 
care be taken the child may be seriously injured. As the disease 
advances the patient becomes incoherent and rambling in her talk, 
and, in a fully developed case, she is incessantly pouring forth an un- 
connected jumble of sentences, out of which no meaning can be made. 
Often some prevalent idea which is dwelling in the patient's mind can 
be traced running through her ravings, and it has been noticed that 
this is frequently of a sexual character, causing women of unblemished 
reputation to use obscene and disgusting language, which it is difficult 
to understand their even having heard. The tendency of such patients 
to make accusations impugning their own chastity was specially insisted 
on by many eminent authorities in a recent celebrated trial, when Sir 
James Simpson stated that in his experience " the organ diseased gave 
a type to the insanity, so that with women suffering with affections of 
the genital organs the delusions would be more likely to be connected 
with sexual matters." Eeligious delusions — as a fear of eternal damna- 
tion, or of having committed some unpardonable sin — are of frequent 
occurrence, but perhaps more often in cases which are tending to the 
melancholic type. There is generally intolerable restlessness, and the 
patient's whole manner and appearance are those of excessive excite- 
ment. She may refuse to remain in bed, may tear off her clothes, or 
attempt to injure herself. The suicidal tendency is often very marked. 
In one ease under my care the patient made incessant efforts to destroy 
herself, which were only frustrated by the most careful watching; she 
endeavored to strangle herself with the bedclothes, to swallow any 
article she could lay hold of, and even to gouge out her own eyes. 
Food is generally persistently refused, and the utmost coaxing may 
fail in inducing the patient to take nourishment. The pulse is rapid 
and small, and the more violent the excitement and furious the 



620 THE PUERPERAL STATE. 

delirium, the more excited is the circulation. The tongue is coated 
and furred, the bowels constipated and disorded, and the feces, as well 
as the urine, are frequently passed involuntarily. The urine is scanty 
and high-colored, and after the disease has lasted for some time it 
becomes loaded with phosphates. The lochia and the secretion of milk 
generally become arrested at the commencement of the disease. The 
waste of tissue, from the incessant restlessness and movement of the 
patient, is very great ; and if the disease continues for some time she 
falls into a condition of marasmus, which may be so excessive that 
she becomes wasted to a shadow of her former size. 

When the insanity assumes the form of melancholia, its advent is 
more gradual. It may commence with depression of spirits, without 
any adequate cause, associated Avitk insomnia, disturbed digestion, head- 
ache, and other indications of bodily derangement. Such symptoms 
showing themselves in women who have been nursing for a length of 
time, or in whom any other evident cause of exhaustion exists, should 
never pass unnoticed. Soon the signs of mental depression increase 
and positive delusions show themselves. These may vary much in 
their amount, but they are all more or less of the same type, and very 
often of a religious character. The amount of constitutional disturb- 
ance varies much. In some cases which approach in character those 
of mania, there is considerable excitement, rapid pulse, furred tongue, 
and restlessness. Probably cases of acute melancholia, coming on 
during the puerperal state, most often assume this form. In others, 
again, there is less of these general symptoms, the patients are pro- 
foundly dejected, and sit for hours without speaking or moving, but 
there is not much excitement, and this is the form most generally 
characterizing; the insanitv of lactation. In all cases there is a marked 
disinclination to food. There is also, almost invariably, a disposition 
to suicide ; and it should never be forgotten in melancholic cases that 
this may develop itself in an instant, and that a moment's carelessness 
on the part of the attendants may lead to disastrous results. 

Treatment. — Bearing in mind what has been said of the essential 
character of puerperal insanity, it is obvious that the course of treat- 
ment must be mainly directed to maintain the strength of the patient, 
so as to enable her to pass through the disease without fatal exhaustion 
of the vital powers, while Ave endeavor at the same time to calm the 
excitement and giA T e rest to the disturbed brain. Any oA^er-actiA'e 
measures — for example, bleeding, blistering the shaven scalp, and the 
like — are distinctly contra-indicated. 

There is a general agreement on the part of alienist physicians that 
in cases of acute mania the two things most needed are a sufficient 
quantity of suitable food and sleep. 

Every endeaA'or should be made to induce the patient to take plenty 
of nourishment to remedy the defects of the excessiA^e Avaste of tissue 
and support her strength until the disease abates. Dr. Blandford, who 
has especially insisted on the importance of this, says : l "Now with 
regard to the food, skilful attendants Avill coax a patient into taking a 

1 Blandford : Insanity and its Treatment. 






PUERPERAL INSANITY. 621 

large quantity, and we can hardly give too much. Messes of minced 
meat with potato and greens, diluted with beef-tea, bread and milk, 
rum and milk, arrowroot, and so on, may be got down. Never give 
mere liquids as long as you can get down solids. A- the malady 
progresses, the tongue and mouth may become ><> dry and foul that 
nothing but liquids can be swallowed ; but, reserving our beef-tea and 
brandy, let ns give plenty of solid food while Ave can." 

The patient may in mania, as well as in melancholia, perhaps even 
more in the latter, obstinately refuse to take oourishment at all, and 
we may be compelled to use force. Various contrivances have been 
employed for this purpose. One of the simplest is introducing a 
dessertspoon forcibly between the teeth, the patient being controlled 
by an adequate number of attendants, and slowly injecting into the 
mouth suitable nourishment by an India-rubber bottle with an ivory 
nozzle, such as is sold by all chemists. Care must be taken not to 
inject more than an ounce at a time, and to allow the patient to breathe 
between each deglutition. So extreme a measure will seldom be 
required if the patient have experienced attendants who can overcome 
her resistance to food by gentler means; but it may be essential, and 
it is far better to employ it than to allow the patient to become ex- 
hausted from want of nourishment. In one case I had to feed a patient 
in this way three times a day for several weeks, and used for the 
purpose a contrivance known in asylums as Paley's feeding-bottle, 
which reduced the difficulty of the process to a minimum. Beef-tea 
or strong soup, mixed with some farinaceous material, such as Reva- 
lenta Arabica or wheaten flour, or milk, forms the best mess for this 
purpose. 

In the early stages the patient is probably better without stimulants, 
which seem only to increase the excitement. As the disease progresses 
and exhaustion becomes marked, it may be necessary to have recourse 
to them. In melancholia they seem to be more useful, aud may be 
administered with greater freedom. 

The state of the bowels requires especial attention. They are almost 
always disordered, the evacuations being dark and offensive iu odor. 
Iu the early stages of the disease the prompt clearing of the bowels by 
a suitable purgative sometimes has the effect of cutting short an im- 
pending attack. A curious example of this is recorded by Gooch, in 
which the patient's recovery seemed to date from the free evacuation 
of the bowels. A few grains of calomel, or a dose of compound jalap 
powder, or of castor oil, may generally be readily given. During the 
continuance of the illness the state of the prima? vise should be attended 
to, aud occasional aperients will be useful, but strong and repeated 
purgation is hurtful from the debility it produces. 

One of the most important points of treatment is to procure sleep. 
For this purpose there is no drug so valuable as the hydrate of choral, 
either alone or in combination with bromide of potassium, which has 
a distinct effect in increasing its hypnotic action. Given in a full dose 
at bedtime, say from fifteen grains to half a drachm, it rarely fails in 
procuring at least some sleep, and in an early stage of acute mania 
this may be followed by the best effects. It may be necessary to 



622 THE PUERPEKAL STATE. 

repeat this draught night after night, during the acute stage of the 
malady. If we cannot induce the patient to sruallow the medicine it 
may be given in the form of enema. 

It is generally admitted that in mania, preparations of opium, for- 
merly much relied on in the treatment of the disease, are apt to do 
more harm than good. Dr. Blandford gives a strong opinion on this 
point. He says : u In prolonged delirious mania I believe opium 
never does good, and may do great harm. We shall see the effects of 
narcotic poisoning if it be pushed, but none that are beneficial. This 
applies equally to opium given by the mouth and by subcutaneous 
injection. The latter, as it is more certain and effectual in producing 
good results, is also more deadly when it acts as a narcotic poison. 
After the administration of a dose of morphia by the subcutaneous 
method, the patient will probably at once fall asleep, and we con- 
gratulate ourselves that our long- wished -for object is attained. But 
after half an hour or so the sleep suddenly terminates, and the mania 
and excitement are worse than before. Here you may possibly think 
that, had the dose been larger, instead of half an hour's sleep you 
would have obtained one of longer duration, and you may administer 
more, but with a like result. Large doses of morphia not merely fail 
to produce refreshing sleep ; they poison the patient, and produce, if 
not the symptoms of actual narcotic poisoning, at any rate that typhoid 
condition which indicates prostration and approaching collapse. I 
believe there is no drug the use of which more often becomes abused 
than that of opium." It is otherwise in cases of melancholia, espe- 
cially in the more chronic forms. In these, opiates in moderate doses, 
not pushed to excess, may be given with great advantage. The sub- 
cutaneous injection of morphia is by far the best means of exhibiting 
the drug, from its rapidity of action and facility of administration. 

There are other methods of calming the excitement of the patient 
besides the use of medicines. The prolonged use of the warm bath, 
the patient being immersed in water at a temperature of 90° or 92 a 
for at least half an hour, is highly recommended by some as a sedative. 
The wet pack serves the same purpose, and is more readily applied in 
refractory subjects. 

Judicious nursing" is of primary importance. The patient should 
be kept in a cool, well-ventilated, and somewhat darkened room. If 
possible she should remain in bed, or, at least, endeavors should be 
made to restrain the excessive restless motion which has so much effect 
in promoting exhaustion. The presence of relatives and friends, espe- 
cially the husband, has generally a prejudicial and exciting effect; and 
it is advisable to place the patient under the care of nurses experienced 
in the management of the insane, Avho, as strangers, are likely to have 
more control over her. It is not too much to say that much of the 
success in treatment must depend on the manner in which this indica- 
tion is met. Rough, unskilled nurses, who do not know how to use 
gentleness combined with firmness, will certainly aggravate and pro- 
long the disorder. Inasmuch as no patient should be left unwatched 
by day or night, more than one nurse is essential. 

The question of the removal of the patient to an asylum is one 



PUERPERAL SEPTICAEMIA. 623 

which will give rise to anxious consideration. As the fact of having 
been under such restraint of necessity fixes a certain Lasting stigma upon 
a patient, this is a step which everyone would wish to avoid if possible. 

In eases of acute mania, which will probably last a comparatively 
short time, home treatment can generally be efficiently carried out. 
Much must depend on the circumstances of the patient. If these be 

of a nature which preclude the possibility of her obtaining thoroughly 
efficient nursing and treatment in her own home, it is advisable to 
remove her to a place where these essentials can be obtained, even at 
the cost of some subsequent annoyance. In cases of chronic melan- 
cholia, the management of which is on the whole more difficult, the 
necessity for such a measure is more likely to arise, and should not be 
postponed too late. Many examples of incurable dementia arising out 
of puerperal melancholia can be traced to unnecessary delay in placing 
the patients under the most favorable conditions for recovery. 

Treatment during" Convalescence. — When convalescence is com- 
mencing, change of air and scene will often be found of great value. 
Removal to some quiet country place, where the patient can enjoy 
abundance of air and exercise, in the company of her nurses, without 
the excitement of seeing many people, is especially to be recommended. 
Great caution must be used in admitting the visits of relatives and 
friends. In two cases under my own care the patients relapsed, when 
apparently progressing favorably, because the husbands insisted, con- 
trary to advice, on seeing them. On the other hand, Gooch has 
pointed out that when the patient is not recovering, when month after 
month has been passed in seclusion without any improvement, the 
visit of a friend or relative may produce a favorable moral impression 
and inaugurate a change for the better. It is probably in cases of 
melancholia, rather than in mania, that this is likely to happen. The 
experiment may, under such circumstances, be worth trying ; but it is 
one the result of which we must contemplate with some anxiety. 



CHAPTEE V. 

PUERPERAL SEPTICEMIA. 

Difference of Opinion as to Puerperal Fever. — There is no subject 
in the whole range of obstetrics which has caused so much discussion 
and difference of opinion as that to which this chapter is devoted. 
Under the name of puerperal fever, the disease we have to consider has 
given rise to endless controversy. One writer after another has stated 
his view of the nature of the affection with dogmatic precision, often 
on no other grounds than his own preconceived notions and an 
erroneous interpretation of some of the post-mortem appearances. 



624 THE PUERPERAL STATE. 

Thus, one states that puerperal fever is only a local inflammation, 
such as peritonitis ; others declare it to be phlebitis, metritis, metro- 
peritonitis, or an essential zymotic disease sui generis, which affects 
lying-in women only. The result has been a hopeless confusion ; and 
the student rises from the study of the subject with little more useful 
knowledge than when he began. Fortunately, modern research is 
beginning to throw a little light upon this chaos. 

Modern View of the Disease. — The whole tendency of recent in- 
vestigation is daily rendering it more and more certain that obstetri- 
cians have been led into error by the special virulence and intensitv of 
the disease, and that they have erroneously considered it to be some- 
thing special to the puerperal state, instead of recognizing in it a form 
of septic disease practically identical with that which is familiar to sur- 
geons under the name of pyaemia or septicaemia, generally produced 
by the pathogenic infection of lesions of continuity in the parturient 
canal, resulting from separation of the decidua and placenta, or from 
lacerations of the cervix, vagina, or perineum. 

If this view be correct, the term " puerperal fever," conveying the 
idea of a fever such as typhus or typhoid, must be acknowledged to 
be misleading, and one that should be discarded, as onlv tending to 
confusion. Before discussing at length the reasons which render it 
probable that the disease is in no way specific or peculiar to the puer- 
peral state, it will be well to relate briefly some of the leading facts 
connected with it. 

History. — More or less distinct references to the existence of the 
so-called puerperal fever are met with in the classical authors, prov- 
ing beyond doubt that the disease was well known to them ; and 
Hippocrates, besides relating several cases, the nature of which is un- 
questionable, clearly recognizes the possibility of its originating in the 
retention and decomposition of portions of the placenta. Harvey and 
other writers showed that they were more or less familiar with it, and 
even made most creditable observations on its etiology ; the actual name 
"puerperal fever" was first used by Strother 1 in 1716, but it was not 
until the latter half of the last century that it came prominently into 
notice. At that time the frightful mortality occurring at some of the 
principal lying-in hospitals, especially in the Hotel Dieu at Paris, 
attracted attention, and ever since the disease has been familiar to 
obstetricians. 

Mortality in Lying-in Hospitals. — Its prevalence in hospitals in 
which lying-in women are congregated has been constantly observed 
both in this country and abroad, occasionally producing an appalling 
death-rate ; the disease, when once it has appeared, frequently spread- 
ing from one patient to another in spite of all that could be done to 
arrest it. It would be easy to give many startling instances of this. 
Thus it prevailed in London in the years 1760, 1768, and 1770 to 
such an extent that in some lying-in institutions nearly all the patients 
died. Of the Edinburgh Infirmary, in 1773, it is stated that " almost 
every woman, as soon as she was delivered, or perhaps about twenty- 

1 Criticon Febrium. 1716. 



PUERPERAL SEPTICEMIA. 625 

four hours after, was seized with it, and all of them died, though every 
effort was made to cure the disorder." On the Continent, where the 
lying-in institutions are on a much larger scale, the mortality was 
equally great. Thus in the Maison d'Accouchements of Paris, in a 
number of different years, sometimes as many as 1 in 3 of the women 
delivered died; on one occasion 10 women dying out of 15 delivered. 
Similar results were observed in other great Continental hospitals, as 
in Vienna, where, in 1823, 15) per cent, of the eases died, and in 1842, 
16 per cent. ; and in Berlin, in 1802, hardly a single patient escaped, 
the hospital being eventually closed. 

Such facts, the correctness of which is beyond any question, prove 
to demonstration the great risk which may accompany the aggregation 
of lying-in women. It is to be observed, however, that the cases in 
which the disease produced such disastrous results occurred before our 
more recent knowledge of its mode of propagation was acquired, when 
no sufficient hygienic precautions were adopted, when ventilation was 
little thought of, and when, in a word, every condition prevailed that 
would tend to favor the spread of a contagious disease from one patient 
to another. More recent experience proves that, when the contrary is 
the case, the occurrence of epidemics of this kind may be entirely pre- 
vented, and the mortality approximated to that of the best class of 
home practice. The results almost universally obtained of late years 
by the introduction of strict antisepsis into lying-in institutions afford 
a most instructive commentary upon the causes of puerperal fever. 
Thus, in the Maternite, in Paris, the mortality from 1858 to 1870 
was 1 in 11 ; at the present time it is only 1 in 100. At the Foundling 
Hospital in St. Petersburg the mortality before the introduction of 
antiseptics was 1 in 27 ; since their use 1 in 147. Similar satisfactory 
results have been reported in lying-in institutions in London, and 
in America — indeed universally wherever antiseptic precautions have 
been adopted. 1 There is, indeed, no more striking chapter in the history 
of modern medicine than this. Formerly a woman who was delivered 
in a lying-in hospital ran a risk not far short of some of the capital 
operations ; now she is as safe in one of them, perhaps safer, than if 
she was confined in one of the most sumptuous of private houses. 

The more closely the history of these outbreaks in hospitals is 
studied, the more apparent does it become that that they are not 
dependent on any miasm necessarily produced by the aggregation of 
puerperal patients, but on the direct conveyance of septic matter from 
one patient to another. 

In numerous instances the disease has been said to be generally 
epidemic in domiciliary practice, much in the same way as scarlet 
fever or any zymotic complaint might be. Such epidemics are 
described as having occurred in London in 1827-28, in Leeds in 
1809-12, in Edinburgh in 1825, and many others might be cited. 
There is, however, no sufficient ground for believing that the disease 
has ever been epidemic in the strict sense of the word. That numerous 
cases have often occurred in the same place and at the same time is 

1 See "The Prevention of Lying-in Fever," by Vassily Sutugin, Edin. Med. Journ., vol. 1884-85, 
p. 781. 

40 



626 THE PUEEPERAL STATE. 

beyond question ; but this can easily be explained without admitting 
an epidemic influence — knowing, as we do, how readily septic matter 
may be conveyed from one patient to another. In many of the so- 
called epidemics the disease has been limited to the patients of certain 
mid wives or practitioners, Avhile those of others have entirely escaped : 
a fact easily understood on the assumption of the disease being pro- 
duced by septic matter conveyed to the patient, but irreconcilable witb 
the view of general epidemic influence. We are not in possession of 
any reliable statistics of the mortality arising from puerperal septi- 
caemia in ordinary general practice. It has, however, been well pointed 
out in the Report on Puerperal Fever, presented by the Obstetrical 
Society of Berlin to the Prussian Minister of Health, 1 that not only 
do the published returns of death from metria afford no reliable esti- 
mate of the actual mortality from this source, but that they are very 
far more numerous than deaths from any other cause in connection 
with pregnancy and childbirth. 

Theories advanced regarding its Nature. — It would be a useless 
task to detail at length the theories that have been advanced to explain 
the disease. Indeed, it may safely be held that the supposed necessity 
of providing a theory which would explain all the facts of the disease 
has done more to surround it with obscurity than even the difficulties 
of the subject itself. If any real advance is to be made, it can only be 
by adopting a humble attitude, by admitting that we are only on the 
threshold of the inquiry, and by a careful observation of clinical facts, 
without drawing from them too positive deductions. 

Theory of its Local Origin. — Many have taught that the disease 
is essentially a local inflammation, producing secondary constitutional 
effects. This view doubtless originated from too exclusive attention 
to the morbid changes found on post-mortem examination. Extensive 
peritonitis, phlebitis, inflammation of the lymphatics or of the tissues 
of the uterus, are very commonly found after death ; and each of these 
has, in its turn, been believed to be the real source of the disease. This 
view finds but little favor with modern pathologists, and is in so many 
ways inconsistent with clinical facts that it may be considered to be 
obsolete. No one of the conditions above mentioned is universally 
found, and in the worst cases definite signs of local inflammation may 
be entirely absent. Nor will this theory explain the conveyance of 
the disease from one patient to another, or the peculiar severity of the 
constitutional symptoms. 

Theory of an Essential Zymotic Fever. — A more admissible 
theory, and one which has been extensively entertained, is that there 
is an essential zymotic fever peculiar to, and only attacking puerperal 
women, which is as specific in its nature as typhus or typhoid, and to 
which the local phenomena observed after death bear the same relation 
that the pustules on the skin do to smallpox, or the ulcers in the 
intestinal glands to typhoid. This fever is supposed to spread by con- 
tagion and infection, and to prevail epidemically both in private and 
in hospital practice. The most recent exponent of this view, Fordyce 

1 " Denkschrift der Puerperal fieber- Commission," Zeitschrift f. Geb. u. Gyn., 1878, Band iii. S. l r 
translated in Edin. Med. Journ., vol. 1878-79, p. 435. 



PUERPERAL SEPTICEMIA. 627 

Barker, in his excellent work on the Puerperal Diseased, entered 
at Length into all the theories of the disease. He, like all others 

holding his opinions, entirely failed, I cannot hilt think, to bring 
forward any conclusive evidence of the existence of such a specific 

fever. It is no doubt true that in typhus and typhoid, and other 
undoubted examples of this class of disease, there are well-marked 
loeal secondary phenomena ; but then they are distinct and constant. 
He makes no attempt to prove that anything of the kind occurs in 
puerperal fever. On the contrary, probably there are no two cases in 
which similar local phenomena occur; nor is there any case in which 
the most practised obstetrician could foretell either the course and 
duration of the illness or the loeal phenomena. Again, this theory 
altogether tails to explain the very important class of cases which can 
be distinctly traced to the absorption of septic matter from decompos- 
ing coagula and the like. Barker meets this difficulty by placing such 
cases under a separate category, admitting that they are examples of 
septicaemia. But he fails to show any difference in symptomatology 
or post-mortem sigus between them and the cases that he believes to 
depend on an essential fever ; nor would it be possible to distinguish 
the one from the other by either their clinical or pathological history. 

Theory of its Identity with Surgical Septicaemia. — The modern 
view, which holds that the disease is, in fact, identical with the con- 
dition known as pyaemia or septicaemia, is by no means free from 
objections, and much patient clinical investigation is required to give 
a satisfactory explanation of certain peculiarities which the disease 
presents ; but in spite of these difficulties, which time may serve to 
remove, it offers a far better explanation of the phenomena observed 
than any other that has yet been advanced. 

According to this theory, the so-called puerperal fever is produced 
by the absorption of septic matter into the system, through solutions 
of continuity in the generative tract, such as always exist after labor. 
It is not essential that the poison should be peculiar or specific ; for, 
just as in surgical pyaemia, any decomposing organic matter may set 
up the morbid action. 

In describing the disease under discussion, I shall assume that, so 
far as our present knowledge goes, this view is the one most consonant 
with facts ; but, bearing in mind that very little is yet known of 
surgical septicaemia, it must not be expected that obstetricians can 
satisfactorily explain all the phenomena they observe. 

The best basis of description I know of is that given by Burdon 
Sanderson, when he says: " In every pysemic process you may trace a 
focus, a centre of origin, lines of diffusion or distribution, and secondary 
results from the distribution. In every case an initial process from 
which infection commences, from which the infection spreads, and 
secondary processes which come out of this primary one." 1 Adopting 
this division, I shall first treat of the mode in which the infection may 
commence in obstetric cases, and point out special difficuties which 
this part of the subject presents. 

1 Clinical Transactions, vol. vii. p. 108. 



628 THE PUERPERAL STATE. 

Channels through which Septic Matter may be Absorbed. — 
The fact that all recently delivered women present lesions of continuity 
in the generative tract, through which septic matter brought into con- 
tact with them may be readily absorbed, has long been recognized. 
The analogy between the interior of the uterus after delivery and the 
surface of a stump after amputation was particularly insisted on by 
Cruveilhier, Simpson, and others — an analogy which was, to a great 
extent, based on erroneous conceptions of what took place — since they 
conceived that the whole interior of the uterus was bared. It is now 
well known that such is not the case ; but the fact remains that at the 
placental site, at any rate, there are open vessels through which absorp- 
tion may readily take place. That absorption of septic material occurs 
through this channel is probable in certain cases in which decomposing 
materials exist in the interior of the uterus, especially when, from 
defective uterine contraction, the venous sinuses are abnormally patu- 
lous and are not occluded by thrombi. It is difficult to understand 
how septic matter introduced from without can reach the placental site. 
Other sites of absorption are, however, always available. These exist 
in every case in the form of slight abrasions or lacerations about the 
cervix or in the vagina, or, especially in prinriparae, about the four- 
chette and perineum. There is even some reason to think that absorp- 
tion of septic matter may take place through the mucous membrane of 
the vagina or cervix without anv breach of surface. This mioht serve 
to account for the occasional, though rare, cases in which the symptoms 
of the disease develop themselves before delivery, or so soon after it as 
to show that the infection must have preceded labor ; nor is there any 
inherent improbability in the supposition that septic material may be 
occasionally absorbed through the unbroken mucous membrane, as is 
certainly the case with some poisons, for example that of syphilis. 
Hence there is no difficulty in recognizing the similarity of a lying-in 
woman to a patient suffering from a recent surgical lesion, or in under- 
standing how septic matter conveyed to her, during or shortly after 
labor, may be absorbed. It is necessary, however, to suppose that 
absorption takes place immediately or very shortly after these lesions 
of continuity are formed, for it is well known that the power of absorp- 
tion is arrested after they have commenced to heal. This fact may 
explain the cases in which sloughing about the perineum or vagina 
exists without any septicaemia resulting, or the far from uncommon 
cases in which an intensely fetid lochia! discharge may be present a 
few days after delivery without any infection taking place. 

The character and sources of the septic matter constitute one of the 
most obscure questions in connection with septicaemia, and that which 
is most open to discussion. 

Division into Autogenetic and Heterogenetic Cases. — A popular 
division of the subject has been into cases in which the septic matter 
originates within the patient, so that she infects herself, the disease 
then being autogenetic ; and into those in which the septic matter is 
conveyed from without and brought into contact with absorptive sur- 
faces in the generative tract, the disease then being heterogenetic. 

Of late the term autogenetic has been objected to on the ground 



PUERPERAL SEPTICEMIA. ()29 

that retained coagula and the like, contained within the person of the 
patient, would not oi' themselves decompose and give rise to infec- 
tion unless microbes had found their way to them from without and 
set up decomposition. In this strict sense the word may be admitted 
to be inaccurate. At the same time the division was a very practical 
one, and it laid stress on the danger of leaving organic structures, 
such as portions of placenta, membranes, or clots, within the genital 
tract. With this explanation, therefore, the division may be retained. 
It is supposed that disease of this type originates from saprsemic in- 
toxication due to the absorption of poisonous materials resulting 
from putrefactive changes, bttt that it differs from the septic infec- 
tion, inasmuch as organisms do not invade the tissues and multiply 
in them. Clinically, however, the two types of disease cannot be 
distinctly differentiated, and it is admitted that they may be com- 
bined, true pathogenic micrococci finding a congenial soil in the 
decomposing structures, and subsequently invading the tissues. The 
former class of disease may be termed saprczmia, corresponding to cases 
which have been described as autogenetic ; the latter septiccemia, corre- 
sponding to the heterogenetic type. 

Sources of Saprsemia or Self-infection. — The sources of sapremia 
may be various, but they are not difficult to understand. Any condi- 
tion giving rise to decomposition, either of the tissues of the mother 
herself, of matters retained in the uterus or vagina that ought to have 
been expelled, or decomposing matter derived from a putrid foetus, 
may start the the septicemic process. Thus it may happen that from 
continuous pressure on the maternal soft parts during labor, sloughing 
has set in ; or there may be already decomposing material present from 
some previous morbid state of the genital tract, as in carcinoma. A 
more common origin is the retention of coagula, or of small portions 
of membrane, or of placenta, in the interior of the uterus, which have 
putrefied from access of air; or in the decomposition of the lochia. 
That the retention of portions of the placental tissue has at all times 
been the cause of septicemia may be illustrated by the case of the 
Duchesse d'Orleans (in the time of Louis XIII.), who had an easy 
labor, but died of childbed fever. An examination was made by the 
leading physicians of Paris, in their report of which it was stated : 
"On the right side of the womb was found a small portion of after- 
birth, so firmly adherent that it could hardly be torn off by the finger- 
nails." 1 The reason why self-infection does not more often occur 
from such sources, since more or less decomposition is of necessity so 
often present, has already been referred to in the fact that absorption 
of such matters is not apt to occur when the lesions of continuity, 
always existing after parturition, have commenced to heal. This 
observation may also serve to explain how previous bad states of 
health, by interfering with the healthy reparative process occurring 
after delivery, may predispose to self-infeetion. It is interesting to 
note that puerperal septicemia, arising from such sources, is not lim- 
ited to the human race. In the debate on pyaemia at the Clinical 

1 Louise Bourgeois, by Goodell. 



630 THE PUERPERAL STATE. 

Society, Mr. Hutchinson recorded several well-marked examples 
occurring in ewes, in whose uteri portions of retained placenta were 
found. 

Source of Heterogenetic Infection. — The sources of septic matter 
conveyed from without are much more difficult to trace, and there are 
many facts connected with heterogenetic infection which are very diffi- 
cult to reconcile with theory, and of which, it must be admitted, we 
are not yet able to give a satisfactory explanation. 

It is probable that any decomposing organic matter may infect, but 
that some forms operate Avith more certainty and greater virulence 
than others. 

One of these, which has attracted special attention, is what may be 
termed cadaveric poison, derived from dissection of the dead subject 
in the anatomical and post-mortem theatres, and conveyed to the 
genital tract by the hands of the accoucheur. Attention was particu- 
larly directed to this source of infection by the observations of Sem- 
melweiss, who showed that in the division of the Vienna Lying-in 
Hospital attended by medical men and students who frequented the 
dissecting-rooms the mortality was seldom less than one in ten, while 
in the division solely attended by women the mortality never exceeded 
one in thirty-four; the number of deaths in the former division at 
once falling to that of the latter so soon as proper precautions and 
means of disinfection were used. Many other facts of a like nature 
have since been recorded Avhich render this origin of puerperal septi- 
caemia a matter of certainty. An interesting example is related by 
Simpson with characteristic candor: "In 1836 or 1837, Mr. Sidey, of 
this city, had a rapid succession of five or six cases of puerperal fever 
in his practice, at a time when the disease was not known to exist in 
the practice of any other practitioners in the locality. Dr. Simpson, 
who had then no firm or proper belief in the contagious propagation 
of puerperal fever, attended the dissection of Mr. Sidey's patients 
and freely handled the diseased parts. The next four cases of mid- 
wifery which Dr. Simpson attended were all affected with puerperal 
fever, and it was the first time he had seen it in practice. Dr. Patter- 
son, of Leith, examined the ovaries, etc. The next three cases which 
Dr. Patterson attended in that town were attacked with the disease." * 
Negative examples are of course brought forward, of those who have 
attended post-mortem examinations without injury to their obstetric 
patients, which merely prove that the cadaveric poison does not, of 
necessity, attach itself to the hands of the dissector ; no amount of 
such testimony can invalidate such positive evidence as that just 
narrated. Barnes believes that there is not so much danger attending 
the dissection of patients who have died of any ordinary disease, but 
that the risk attending the dissection of those who have died of infec- 
tious or contagious complaints is very great indeed. 2 I presume there 
is no doubt that the risk is greater when the subject has died from 
zymotic disease ; but the distinction is too delicate to rely on, and the 
attendant on midwifery will certainly err on the safe side by avoiding 

i Selected Obstetric Works, p. 508. 

2 '• Lectures on Puerperal Fever " Lancet, 1865, vol. ii. p. 112. 



PUERPERAL SEPTICEMIA. 631 






as much as possible having anything to do with the conduct of dissec- 
tions or post-mortem examinations. 

Infection from Erysipelas. — Another possible source of infection 
is erysipelatous disease in all its forms. The intimate connection 
between erysipelas and surgical pyaemia has long been recognized by 
surgeons, and the influence of erysipelas in producing puerperal septi- 
cemia has been specially observed in surgical hospitals into which 
lying-in patients were also admitted. Trousseau relates instances of 
this kind occurring in Paris. The only instance that I know of in 
London was in the lying-in ward of King's College Hospital, where, 
in spite of every hygienic precaution, the mortality was so great as to 
necessitate the closure of the ward. Here the association of erysipelas 
with puerperal septicaemia was again and again observed; the latter 
proving fatal in direct proportion to the prevalence of the former in 
the surgical wards. The dependence of the tw T o on the same poison 
was in one instance curiously shown by the fact of the child of a 
patient who died of puerperal septicaemia dying from erysipelas which 
started from a slight abrasion produced by the forceps. A more 
recent and very remarkable example is related by Dr. Lombe Atthill. 1 
A patient suffering from erysipelas was admitted into the Rotunda 
Hospital on February 15, 1877. The sanitary condition of the hos- 
pital was at the time excellent. The patient Avas removed next day, 
but of the next 10 patients confined in adjoining wards, 9 were attacked 
with puerperal peritonitis, the only one who escaped being a case of 
abortion. But the connection between erysipelas and puerperal septi- 
caemia is not limited to hospitals, having been observed in domiciliary 
practice. Some interesting facts have been collected by Dr. Minor, 2 
who has shown that the two diseases have frequently prevailed 
together in various parts of the United States, and that during a 
recent outbreak of puerperal fever in Cincinnati it occurred chiefly in 
the practice of those physicians who attended cases of erysipelas. 
Many children also died from erysipelas w r hose mothers had died from 
puerperal fever. 

Infection from other Zymotic Diseases. — There is good reason to 
believe that the contagium of other zymotic diseases may produce a 
form of disease indistinguishable from ordinary puerperal septicaemia, 
and presenting none of the characteristic features of the specific com- 
plaint from which the contagium was derived. This is admitted to 
be a fact by the majority of our most eminent British obstetricians, 
although it does not seem to be allowed by Continental authorities, 
and it is strongly controverted by some writers in this country. It is 
certainly difficult to reconcile this with the theory of septicaemia, and 
we are not in a position to give a satisfactory explanation of it, I 
believe, however, that the evidence in favor of the possibility of 
puerperal septicaemia originating in this way is too strong to be assail- 
able. 

The scarlatinal poison is that regarding which the greatest number 
of observations have been made. N umerous cases of this kind are to 



1 Medical Press and Circular, January-June, 1877, p. 

2 Erysipelas and Childbed Fever. Cincinnati, 1874. 



632 THE PUERPERAL STATE. 

be found scattered through our obstetric literature, but the largest 
number are to be met with in a paper by Dr. Braxton Hicks in the 
twelfth volume of the Obstetrical Transactions, and they are especially 
valuable from that gentleman's well-known accuracy as a clinical 
observer. Out of 68 cases of puerperal disease seen in consultation, 
no less than 37 were distinctly traced to the scarlatinal poison. Of 
these 20 had the characteristic rash of the disease ; but the remaining 
17, although the history clearly proved exposure to the contagium of 
scarlet fever, showed none of its usual symptoms, and were not to be 
distinguished from ordinary typical cases of the so-called puerperal 
fever. On the theory that it is impossible for the specific contagious 
diseases to be modified by the puerperal state, we have to admit that 
one physician met with 17 cases of puerperal septicaemia in which, by 
a mere coincidence, the contagion of scarlet fever had been traced, 
and that the disease nevertheless originated from some other source 
— an hypothesis so improbable that its mere mention carries its own 
refutation. 

With regard to the other zymotic diseases the evidence is not so 
strong ; probably from the comparative rarity of the diseases. Hicks 
mentions one case in which the diphtheritic poison was traced, although 
none of the usual phenomena of the disease were present. I lately 
saw a case in which a lady, a few days after delivery, had a very 
serious attack of septicaemia, without any diphtheritic symptoms, her 
husband being at the same time attacked with diphtheria of a most 
marked type. Here it would be difficult not to admit the dependence 
of the two diseases on the same poison. 

It is, however, certain that all the zymotic diseases may attack a 
newly delivered woman, and run their characteristic course without 
any peculiar intensity. Probably most practitioners have seen cases 
of this kind ; and this is precisely one of the points of difficulty which 
we cannot at present explain, but on which future research may be 
expected to throw some light. It seems to me not improbable that 
the explanation of the fact that zymotic poison may, in one puerperal 
patient, run its ordinary course, and in another produce symptoms of 
intense septicaemia, may be found in the channel of absorption. It is, 
at any rate, comprehensible that if the contagium be absorbed through 
the skin or the ordinary channel, it may produce its characteristic 
symptoms and run its usual course ; while, if brought into contact 
with lesions of continuity in the generative tract, it may act more in 
the way of septic poison, or with such intensity that its specific symp- 
toms are not developed. 

It may reasonably be objected that if puerperal and surgical sep- 
ticaemia be identical, the zymotic poisons ought to be similarly modi- 
fied when they infect patients after surgical operations. The subject 
of specific contagium as a cause of surgical pyaemia has been so little 
studied, that I do not think anyone would be justified in asserting that 
such an occurrence is not possible. Fritsch, of Halle, and other 
German physicians have recently shown how elaborate antiseptic pre- 
cautions in lying-in hospitals may prevent the origin of the disease 
from such sources. Sir James Paget, in his Clinical Lectures, seems 



PUERPERAL SEPTICEMIA. 633 

to believe in the possibility of such modification. He says: " I think 
it not improbable that, in some cases, results occurring with obscure 

symptoms, within two or three' days alter operations, have been due to 
scarlet-fever poison, hindered in some way from it.-, usual progress." 
Sir Spencer Wells informs me that he has seen eases of surgical pyaemia 
which he had reason to believe originated in the scarlatinal poison ; 
and his well-known success as an ovariotomist is, no doubt, in a great 
measure to be attributed to his extreme care in seeing that no one 
likely to come in contact with his patients has been exposed to any 
such source of infection. 

Sewer-gas and Defective Sanitary Arrangements. — Exposure 
to sewer-gas may, I feel sure, produce the disease. In two cases of 
the kind I had the opportunity of closely watching an untrapped 
drain opened directly into the bedroom — in one instance into a bath, 
in the other into a Avater-closet. Both cases were indistinguishable 
from the ordinary form of the disease, and in both improvement com- 
menced as soon as the patient was removed into another room. 

In a case I saw some years ago at Notting Hill, the patient, who 
had been confined within a Aveek, had all the symptoms of a most 
intense attack of septicaemia, but none of a diphtheritic character, 
while her husband lay in an adjoining room suffering from a diphthe- 
ritic sore-throat. Here the waste-pipe of the bath was found to com- 
municate directly with the sewer. In spite of her intense illness, I 
had the patient removed to another house, and from that moment she 
began to improve. In two other cases in which the same source of 
disease was detected, the removal of the patient from the infected 
atmosphere was immediately followed by a marked amelioration in the 
symptoms. I know of three similar cases which ended fatally, in 
which I have every reason to believe that the cause of the disease was 
poisoning by sewer-gas. Frankenhanser has related a curious case of 
the poisoning of four puerperal women by sewer-gas. Gustave Braun 1 
ascribes a recent mortality in his clinic of 8.87 per cent, to bad sewer- 
age, his wards being in direct connection with the sewerage svsteni of 
the General Hospital, and near the closets of the adjoining barracks. 
Technical antisepsis had been as faithfully practised as is possible 
where instruction has been given to midwives. In fact, the whole 
question of the influence of defective sanitary conditions on the puer- 
peral state deserves much more serious study than it has ever yet re- 
ceived, and I have long been satisfied that they have often much to do 
with certain grave forms of illness in the lying-in state the origin of 
which cannot otherwise be traced. 2 

i Centralblatt fur Gynak., 1889, No. 36. 

2 Since the above was written, I have published a special paper on this subject (" Defective 
Sanitation as a Cause of Puerperal Disease." Lancet. February 5, 1887). I append from it two 
cases, as I think the diagrams illustrating this source of danger may prove of interest : 

The annexed diagram (Fig. 207) represents a bedroom in a large house in a fashionable part of 
the West End, which had been recently taken and done up in the most costly way. I attended 
the lady of the house in her second confinement, and she lay in her bed at a. Shortly she developed 
well-marked septic symptoms, and I naturally investigated the sanitary state of the house to see 
if it threw any light'on their origin. I could find nothing amiss. There was no bath or fixed 
washstand near the room, and the closets Mere at a distance, with the soil-pipe running down 
the outside wall, as it should do. It was not until some days afterward that I discovered the 
extraordinary arrangement depicted in the diagram, which no one could possibly have suspected, 
and the knowledge of which the patient had given special directions should be withheld from 
me. At b is represented a very handsome and innocent-looking piece of furniture which seemed 



634 



THE PUERPERAL STATE. 



Septicaemia from Contagion Conveyed. — The last source from 
which septic matter may be conveyed is from a patient suffering from 
puerperal septicaemia, a mode of origin which has, of late, attracted 
special attentiou. That this is the explanation of the occasioual 
endemic prevalence of the disease in lying-in hospitals can scarcely be 
doubted. The theory of a special puerperal miasm pervading the 
hospital is not required to account for the facts, for there are a hun- 
dred ways, impossible to detect or avoid — on the hands of nurses or 
attendants, in sponges, bedpans, sheets, or even suspended in the 
atmosphere — in which septic material derived from one patient may 
be carried to another. 

The poison may be conveyed in the same manner from one private 
patient to another. Of this there are many lamentable instances recorded. 
Thus it was mentioned by a gentleman at the recent discussion at the 
Obstetrical Society, that five out of fourteen women he attended died, 
no other practitioner in the neighborhood having a case. This origin 



Fig. 207. 




BED ROOM 



to be a fixed wardrobe, to which purpose its ends were in fact devoted. The centre door, how- 
ever, formed by a large mirror, opened on a concealed water-closet (c), which luxury no one could 

have looked for in such a situation. I subsequently 
discovered that this was a brilliant idea of the hus- 
band's, who actually had had a special soil-pipe 
carried through the centre of the house, which com- 
municated directly with the main drain, with no 
ventilation, and who had thus contrived, at an enor- 
mous cost, to have a stream of sewer-gas laid on 
close to his bedside. And be it remarked that 
builders and plumbers had carried out this inge- 
niously dangerous arrangement without giving the 
slightest hint that it was either unusual or perilous. 
Of course, as soon as I made this discovery I had the 
patient removed to another room, when her symp- 
toms soon abated. 

I could easily go on multiplying examples of this 
kind, but I shall content myself with one more case, 
which was thoroughly worked out, with very in- 
structive results. It was that of a lady who was 
confined of her first child, in the country in a large 
and expensive house, newly built, and supposed to 
be supplied with all the most perfected sanitary 
arrangements. There was nothing particular about 
the labor, and for the first ten days the convalescence 
left nothing to be desired. On the eleventh day she 
got up and lay on the sofa (Fig. 208, d) opposite the 
fire (f), which, as it was in January, was burning 
day and night. The day after, although she had a 
headache and felt poorly, she again got up and lay 
on the sofa. The subsequent day, although feeling 
very ill, she again insisted on getting up, and lay 
on "the sofa at e, in her husband's dressing-room. 
On the following day she was very ill indeed, with 
a temperature of 104° and a pulse of 130, and I was 
summoned to see her. It is needless to say more of 
her illness, which rapidly increased, except that, 
feeling satisfied it was caused by defective sanita- 
tion, I advised her removal to a house in the neigh- 
borhood, in spite of the very grave symptoms that 
existed, with the most satisfactory result, for within 
twenty-four hours her temperature had fallen, and 
she rapidly became convalescent. Of course, at this 
time nothing was known of what actually existed, 
but I was led to form this conclusion from the fact that a number of the servants and residents were 
suffering from sore-throats, and from being told that almost everyone who came to stay felt ill and 
out of sorts. Subsequently the sanitary state of the house was thoroughly investigated by one of the 
most distinguished sanitary engineers in London, from whose reports the accompanying diagram 
(Fig. 208) is copied. It is useless to enter into a description of all the abomination's which were 
found to exist, which, in a house of the kind, in the building of which no expense was spared, 
were almost past belief. For the purpose of my story it will suffice to say that the smoke test 
showed that there was a very abundant escape of sewer-gas in both the bedroom and dressing- 
room, which, from the fact that there were large fires burning constantly in both rooms, passed 
in a continuous current in the direction of the arrows. In addition, the plumbing-work in the 
closet, b, in the dressing-room, had been so imperfectly done that its contents found their way out 
under the floor, e. Now, mark how thoroughly and curiously these facts prove the cause of the 
disease. The patient lay in the bed at c, which, from tne accident of its being winter, and the 




PUERPERAL SEPTICEMIA 



635 



of the disease was clearly pointed out by Gordon 1 toward the end of 
last century, who stated that he himself "was the means of carrying 
the infection to a great number of women," and he also traced the 
spread of the disease in the same way in the practice of certain mid- 
wives. In some remarkable instances the unhappy property of carry- 
ing contagion lias clung to individuals in a way which is most 
mysterious, and which has led to the supposition that the whole system 
becomes saturated with the poison. One of the strangest cases of this 
kind was that of the late Dr. Rutter, of Philadelphia, which caused 
much discussion. He had forty-five cases of puerperal septicaemia in 
his own practice in one year, while none of his neighbors' patients were 
attacked. Of him it is related : " Dr. Rutter, to rid himself of the 
mysterious influence which seemed to attend upon his practice, left the 
city for ten days, and before waiting on the next parturient ease had 
his hair shaved off and put on a wig, took a hot bath, and changed 
every article of his apparel, taking nothing with him that he had worn 

current of sewer-gas being drawn therefore to the chimneys, was quite out of its reach, and for 
the first ten days after her confinement, while she remained in bed, she was perfectly well. On 
the eleventh day, when she got up, she was placed directly in the current of sewer-gas at n, and 
instantly got poisoned. On the twelfth and thirteenth days she was again exposed to the absorp- 
tion of further and more intense poisoning, at e ; while immediately on her removal to fresh and 

Fig. 208. 




uncontaminated air all her threatening symptoms disappeared. Remark also that there was 
nothing peculiar in the symptomatology, nothing different from an ordinary and rapidly progress- 
ing case of puerperal septicemia. It seems to me that this instructive history is about as complete 
a demonstration of the origin of puerperal disease from defective sanitation as anyone could pos- 
sibly desire, and I can see no flaw in the chain of evidence. 
1 See Lectures on Puerperal Fever. By Robert J. Lee, M.D. 



636 THE PUERPERAL STATE. 

or carried, to his knowledge, on any former occasion : and mark the 
result. The lady, notwithstanding that she had an easy parturition, 
was seized the next day with childbed fever, and died on the eleventh 
day after the birth of the child. Two years later he made another 
attempt at self-purification, and the next case attended fell a victim to 
the same disease." Xo wonder that the late Charles D. Meigs, in 
commenting on such a history, refused to believe that the doctor car- 
ried the poison, and rather thought " that he was merely unhappy in 
meeting with such accidents through God's providence." It appears, 
however, that Dr. Butter was the subject of a form of ozama, and it is 
quite obvious that, under such circumstances, his hands could never 
have been free from septic matter. 1 This observation is of peculiar 
interest as showing that the sources of infection may exist in conditions 
difficult to suspect and impossible to obviate, and it affords a satis- 
factory explanation of a case which was for years considered puzzling 
in the extreme. It is quite possible that other similar cases, of which 
many are on record, although none so remarkable, may possibly have 
depended on some similar cause personal to the medical attendant. 

Proby 2 suggests that a similar source of infection may occasionally 
be found in a carious tooth or alveolar abscess, the pus infecting the 
examining finger. 

The sources of septic poison being thus multifarious, a few words 
may be said here as to the mode in which it may be conveyed to the 
patient. 

Mode in -which the Poison may be Conveyed to the Patient. — 
As on the view of puerperal septicaemia which seems most to agree 
with recorded facts, the poison, from whatever source it may be derived, 
must come into actual contact with lesions of continuity in the genera- 
tive tract, it is obvious that one method of conveyance may be on the 
hands of the accoucheur. That this is a possibility, and that the dis- 
ease has often been unhappily conveyed in this way, no one can doubt. 
Still it would be unfair in the extreme to conclude that this is the only 
way in which infection may arise. In town practice, especially, there 
are many other ways in which septic matter may reach the patient. 
The nurse may be the means of communication, and if she has been in 
contact with septic matter she is even more likely than the medical 
attendant to convey it when washing the genitals during the first few 
days after delivery, the time at which absorption is most apt to occur. 
Barnes relates a whole series of cases occurring in a suburb of London, 
in the practice of different practitioners, every one of which was 
attended by the same nurse. Again, septic matter may be carried in 
sponges, linen, and other articles. What is more likely, for example, 
than that a careless nurse might use an imperfectly washed sponge, on 
which discharge has been allowed to remain and decompose ? Xor do 

1 This is stated on the authority of an obstetrical contemporary of Dr. Rutter. See Amer. Journ. 
of Med. Sciences, 1875, vol. lxix. *p. 474. (Minor.) 

The author quotes from the editor. Dr. Rutter had an ozsena which in time much disfigured 
him from its effect upon the contour of his nose. He was unfortunately inoculated in his index 
finger from a patient, and neglected the pustule. He had ninety-five cases of puerperal septicaemia 
in four years and nine months, with eighteen deaths. The question of Dr. Meigs, who was a non- 
contagionist in regard to puerperal peritonitis, was remarkably apposite : " Did he distil a subtle 
essence which he carried with him?"— Harris's note to the third American edition. 

2 Lancet, December 21, 1889. 



PUERPERAL SEPTICAEMIA. 637 

I Bee any reasoD to question the possibility of infection from septic 
matter suspended in the atmosphere ; and in lying-in hospitals, where 
many women arc congregated together, there can be little doubt that 
this is a common origin of the disease, [t is certain, whatever view 
we may take of the character of the septic material, that it must be in 
a state of very minute subdivision, and there is no theoretical difficulty 
in the assumption of its being conveyed by the atmosphere. 

Conduct of the Practitioner in Relation to the Disease. — r J nis 
question naturally involves a reference to the duty of those who are 
unfortunately brought into contact with septic matter in any form, 
either in a patient suffering from puerperal septicaemia, zymotic dis- 
ease, or offensive discharges. The practitioner cannot always avoid 
such contact, and it is practically impossible to relinquish obstetric 
work every time that he is in attendance on a case from which con- 
tagion may be carried. Nor do I believe, especially in these days 
when the use of antiseptics is so well understood, that it is essential. 
It was otherwise when antiseptics were not employed ; but I can 
scarcely conceive any case in which the risk of infection cannot be 
prevented by proper care. The danger I believe to be chiefly in not 
recognizing the possible risk, and in neglecting the use of proper pre- 
cautions. It is impossible, therefore, to urge too strongly the necessity 
of extreme and even exaggerated care in this direction. The prac- 
titioner should accustom himself, as much as possible, to use the left 
hand only in touching patients suffering from infectious diseases, as 
that which is not used, under ordinary circumstances, in obstetric 
manipulations. He should be most careful in the frequent employ- 
ment of antiseptics in washing his hands, such as the 1 : 1000 solution 
of perehlovide of mercury. Clothing should be changed on leaving an 
iufectious case. Much more care than is usually practised should be 
taken by nurses, especially in securing perfect cleanliness in everything 
brought into contact with the patient. AVhen, however, a practitioner 
is in actual and constant attendance on a case of puerperal septicaemia, 
when he is visiting his patient many times a day, especially if he be 
himself washing out the uterus with autiseptic lotions, it is certain that 
he cannot deliver other patients with safety, and he should secure the 
assistance of a brother practitioner, although there seems no reason 
why he should not visit women already confined, in whom he has not 
to make vaginal examinations. 

Prophylaxis of Septicaemia. — If the views here inculcated as to 
the nature and the mode of infection in puerperal septicaemia be correct, 
it is obvious that much may be done in the way of prophylaxis. A 
perfectly aseptic management of puerperal women is practically impos- 
sible. In most lying-in institutions very rigid rules are now laid down 
to prevent the possibility of infective matter beiug conveyed to the 
patient either on the hands of the attendants, or on instruments, 
napkins, and the like, and with the most satisfactory results. As the 
risk is much greater when lying-in women are collected together, such 
precautions, which this is not the place to discuss, are absolutely indi- 
cated. They are not, however, easily applicable in ordinary private 
practice ; but there are certain simple precautions which everyone 



638 THE PUERPERAL STATE. 

might adopt without trouble, which will materially lessen the risk of 
septic poisoning. Among these may be indicated the use of antiseptic 
lotions, with which the practitioner and nurse should always wash their 
hands before attending any case or touching the genital organs ; the use 
of carbolized vaseline, 1 : 8, for lubricating the fingers, catheter, for- 
ceps, etc. ; syringing out the vagina night and morning with creolin 
and water ; rigid attention to cleanliness in bedding, napkins, etc. 
Precautions such as these, although they may appear to some frivolous 
and useless, indicate a recognition of danger and an endeavor to remove 
it, and if they were generally inculcated on nurses (see note, p. 584) 
and others, might go far to prevent the occurrence of septic mischief. 

Nature of the Septic Poison. — As to the precise character of the 
septic poison — although of late much has been said about it, and there 
is good reason to believe that further research may throw light on this 
obscure subject — too little is known to justify any positive statement. 
The researches of Heiberg, Von Recklinghausen, Steurer, and others 
have shown that in puerperal septicaemia, as in surgical fever, erysipelas, 
and other infectious diseases, micrococci in large numbers may be traced 
passing between the muscular and connective-tissue fibres, through the 
lymphatics, and thus into the general circulation, and that they maybe 
found in various organs and pathological products. More recently 
Frankel isolated from a number of cases a chain-forming micrococcus, 
Avhich he at first regarded as specific, and named the streptococcus 
puerperalis. Subsequently he satisfied himself of its identity with a 
similar micro-organism in pus. AVinckel also cultivated a streptococcus 
from a case of puerperal peritonitis. It produced an erysipelatous 
rash in the ear of a rabbit, and was similar in its characters, both mor- 
phologically and in artificial cultivations, to the streptococcus found in 
erysipelas. Cushing found streptococci in endometritis diphtheritica 
and in secondary puerperal inflammation, and Baumgarten, Bumm, 
Pfannestiel, and others have recorded similar observations. Pfanne- 
stiel investigated four cases of puerperal septicaemia with diphtheritic 
endometritis and purulent peritonitis, and he concluded that a specific 
micro-organism could not be differentiated in puerperal fever. In his 
opinion the streptococci from pus, from erysipelas, and diphtheritic 
affections of the pharynx had all the power of setting up puerperal 
septicaemia. Doleris never failed to find streptococci in the blood in 
puerperal septicaemia, and after death they are readily detected in great 
numbers. They do not multiply in the blood during life, but they 
cause changes in both the red and white corpuscles, which stick 
together and form minute capillary infarctions, in which the micrococci 
increase, and from which they invade the surrounding structures and 
produce various pathological changes. These observations are of much 
importance, as tending to confirm by scientific observation the intimate 
relation between these various forms of disease which has long been 
believed to exist. It may be taken as certain that streptococci bear an 
intimate and important relation to the disease ; but whether they them- 
selves form the septic matter or carry it, or whether they are mere 
accidental concomitants of the pyaemic processes, it is impossible, in 
the present state of our knowledge, to decide. 



PUERPERAL SEPTICEMIA. 639 



Channels of Diffusion. — Passing on to the channels of diffusion 
through which the septic matter may act, we have to consider its effects 
on the structures with which it is brought into contact, and the mode 
in which it may infect the system at large; and this will include a 
consideration of the pathological phenomena. 

Local changes consequent on the absorption of the poison are 
pretty constant, and of these we may form an intelligent idea by 
thinking of them as similar in character and causation to those which 
we have the opportunity of studying when septic matter is applied to 
a wound open to observation, as, for example, in cases of blood- 
poisoning following a dissection wound. Distinct traces of local action 
are not of invariable occurrence, and in some of the worst class of 
cases, when the amount of septic matter is great and its absorption 
rapid, death may occur after an illness of short duration but great 
intensity, and before appreciable local changes, either at the site of 
absorption or in the system at large, have had time to develop them- 
selves. The fact that puerperal fever may prove fatal, without leaving 
any tangible post-mortem signs, has often been pointed out, such cases 
most frequently occurring during the endemic prevalence of the disease 
in lying-in hospitals. There can be little doubt, however, that in such 
cases of intense septicemia marked pathological changes exist in the 
form of alterations of the blood and degenerations of tissue, but not 
of a character which can be detected by an ordinary post-mortem 
examination. In the great majority of cases, indications of the disease 
exist at the site of absorption. These are described by pathologists as 
identical in their character Avith the inflammatory oedema which occurs 
in connection with phlegmonous erysipelas. If lacerations exist in 
the cervix or vagina, they take on unhealthy action, their edges 
swell, and their surfaces become covered with a yellowish coat, similar 
in appearance to diphtheritic membrane. The mucous membrane of 
the uterus is also generally found to be affected, and in a degree vary- 
ing with the intensity of the local septic process. There is evidence 
of severe endometritis ; and, very frequently, the whole lining of the 
uterus is profoundly altered, softened, covered with patches of diph- 
theritic deposit, and it may be in a state of general necrosis. In the 
severer cases these changes affect the muscular tissue of the uterus, 
which is found to be swollen, soft, imperfectly contracted, and even 
partially necrosed, a condition which is likened by Heiberg to hospital 
gangrene. The connective tissue surrounding the generative tract is 
also swollen and oedematous, and the inflammation may in this way 
reach the peritoneum, although peritonitis, so often observed in puer- 
peral septicaemia does not necessarily depend on the direct transmission 
of inflammation from the pelvic connective tissue, but is more often a 
secondary phenomenon. 

The channels through which general systemic infection may 
supervene are the lymphatics and the venous sinuses, the former 
being by far the most important. Recent researches have shown the 
great number and complexity of the lymphatics in connection with the 
pelvic viscera, and marked traces of the absorption of septic matter are 
almost always to be found, except in those very intense cases already 



640 THE PUERPERAL STATE. 

alluded to, in which no appreciable post-mortem signs are discover- 
able. The septic matter is probably absorbed from the lymph spaces 
abounding in the connective tissue, and carried along the lymphatic 
canals to the nearest glands. The result is inflammation of their 
coats, and thrombosis of their contents, which may be seen on section 
as a creamy, purulent substance. The absorption of septic material 
may, as Yirchow has shown, be delayed by the local changes produced 
in the lymphatics and in the glands Avith which they communicate, 
which are, therefore, conservative in their action ; and the further 
progress of the case may in this way be stopped and local inflamma- 
tion alone result, such cases being believed by Heiberg to be examples 
of abortive pyaemia. On the other hand, the free septic material may 
be too abundant and intense to be so arrested, it may pass on through 
the lymph canals and glands, until it reaches the blood-current 
through the thoracic duct, and so produces a general blood-infection. 
This mode of absorption of septic matter, and the tendency of the 
glands to arrest its further progress, serve to explain the progressive 
character of many cases, in which fresh exacerbations seem to occur from 
time to time ; since fresh quantities of poison, generated at its source of 
origin, may be absorbed as the case progresses. The uterine veins are 
supposed by D'Espine to be the channel of absorption in the intense 
form of disease which proves fatal very shortly after delivery, too soon 
for the more gradual process of lymphatic absorption to have become 
established. It is evident that the veins are not likely to act in this 
way, since they must, under ordinary circumstances, be completely 
occluded by thrombi, otherwise hemorrhage would occur. If, however, 
uterine contraction be incomplete, the occlusion of the venous sinuses 
may be imperfect, and absorption of septic material through them may 
then take place. Some writers have laid great stress on imperfect 
uterine contraction in predisposing to septicaemia, and its influence 
may thus be well explained. The veins may bear an important part 
in the production of septicaemia, independent of the direct absorption 
of septic matter through them, by means of the detachment of minute 
portions of their occluding thrombi, in the form of emboli. If phleg- 
monous inflammation occurs in the immediate vicinity of the veins, the 
thrombi they contain may become infected. When once blood-infec- 
tion has occurred by any of these channels, general septicaemia, the 
so-called puerperal fever, is developed. 

Four Principal Types of Pathological Change. — The variety of 
pathological phenomena found on post-mortem examination has had 
much to do with the prevalent confusion as to the nature of the disease. 
This has resulted in the description of many distinct forms of puer- 
peral fever, the most marked pathological alteration having been taken 
to be the essential element of the disease. As a matter of fact, there 
is no doubt that various types of pathological change are met with. 
Heiberg describes four chief classes which are by no means distinctly 
separated, are often found simultaneously in the same subject, and 
are certainly not to be distinguished by the symptoms during life. 

Of these the first is the class of cases in which no appreciable morbid 
phenomena are found after death. This formidable and fatal form of 



PUERPERAL SEPTICEMIA. 641 

the disease has long been well known, and is that described by some 
of our authors as adynamic or malignant puerperal fever. It is the 
variety which was so prevalent in our lying-in hospitals, and which 
Ramsbotham talks of as being second only to cholera in the severity 
and suddenness of it- onset and in the rapidity with which it carried 
off its victims. It is quite erroneous to suppose that the existent 
pathological changes in this form of disease has never been recognized. 
Even with the coarse methods of examination formerly used, the 
occurrence of a fluid and altered state of the blood, and ecchymoses 
in connection with various organs — especially the lungs, spleen, and 
kidneys — were noticed and specially described by Coupland in his 
Dictionary of Medicine. More recently it has been clearly proved by, 
the microscope that there exist, in addition, the commencement of 
inflammation in most of the tissues, shown by clondv swellings, and 
granular infiltration and disintegration of the cell element- : proving 
that the blood, heavily charged with septic matter, had set up morbid 
action wherever it circulated, the patient succumbing before this had 
time to develop. 

In the second type, and that perhaps most commonly met with, the 
morbid changes are more frequently found in the serous membranes, 
in the pleura, in the pericardium, but, above all, in the peritoneum, the 
alterations in which have long attracted notice and have been taken 
by many writers as proving peritonitis to be the main element of the 
disease. Evidences of more or less peritonitis are very general. In 
the more severe cases there is little or no exudation of plastic lymph, 
such as is found in peritonitis nnassociated with septicaemia. There 
i- a greater or less quantity of brownish serum only, the coils of in- 
testine, distended with flatus and highly congested, being surrounded 
by it. More often there are patchy deposits of fibrinous exudation 
over many of the viscera, the fundus uteri, the under surface of the 
liver, and the distended intestines. There is then, also, a considerable 
quantity of sero-purulent fluid in the abdominal cavity. The pleural 
cavities may also exhibit similar traces of inflammatory action, con- 
taining imperfectly organized lymph and sero-purulent fluid. Schroeder 
states that pleurisy is more often the direct result of transmission of 
inflammation through the substance of the diaphragm or lung than a 
secondary consequence of the septicaemia. In like manner evidences 
of pericarditis may exist, the surface of the pericardium being highly 
injected and its cavity containing serons fluid. Inflammation of the 
synovial membranes of the larger joints, occasionally ending in sup- 
puration, is not uncommon and may probably be best included under 
this class of cases. 

In the third type the mucous membranes appear to bear the brunt 
of the disease. The pathological change- are most marked in the 
mucous membrane lining the intestines, which i- highly congested and 
even ulcerated in patches, with numerous .-mall spots of blood ex- 
tra va-ated in the submucous tissue. Similar small apoplectic effusions 
have been observed in the substance of the kidneys and under the 
mucous membrane of the bladder. Pneumonia is of common occur- 
rence. In mos - - it is probably secondary to the impaction of 

41 



642 



THE PUERPERAL STATE. 



minute emboli in the smaller branches of the pulmonary artery ; but 
it may doubtless arise from independent inflammation of the lung 
tissue, and will then be included in a class of cases now under con- 
sideration. 

The fourth class of pathological phenomena are those which are 
produced chiefly by the impaction of minute infected emboli in small 
vessels in various parts of the body. These are the cases which most 
closely resemble surgical pyaemia, both in their symptoms and post- 
mortem signs, and which by many writers are described under the 

Fig. 209. 



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A. S., aged thirty years; confined February 27, 1879; died March 10th. 



name of puerperal pyaemia. The dependence of puerperal fever no 
phlebitis of the uterine veins was a favorite theory, and in a large 
proportion of cases the coats of the veins show signs of inflammation, 
their canals being occupied with thrombi in a more or less advanced 
state of disintegration. The mode in which these thrombi may become 
infected has been shown by Babnoff, who has proved that leucocytes 
may penetrate the coats of the vein, and entering its contained coagulum 
may set up disintegration and suppuration. This observation brings 
these pyaemic forms of disease into close relation with septicaemia such 
as we have been studying, and justifies the conclusion of Verneuil 
that purulent infection is not a distinct disease, but only a termination 



PUERPERAL SEPTICEMIA 



643 



of septicaemia, with which it ought to be studied. We have, more- 
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in a subsequent chapter, the characteristic; of these cases being the 
infected nature of the minute emboli. Localized inflammations and 
abscesses, from the impaction of minute capillary emboli, are found in 
many parts of the body ; most frequently in the lungs, then in the 
kidneys, spleen, and liver, and also in the muscles and connective 
tissues. Pathologists are by no means agreed as to the invariable 
dependence of these on embolism, nor is it possible to prove their 



























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DAY OF 
DIS. 


1ST. 


2ND. 


3RD. 


4th. 


5th. 


6th. 


7TH. 


8th 


9TH. 


10TH 


11TH 


12TH. 


13TH 


14TH 




PULSE 




102 




88 


100 




108 


















DATE 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 





Mrs. D., aged twenty-five years; confined May 1, 1879. Puerperal septicaemia; recovery. An 
untrapped pipe, communicating with sewer, was found in bath close to this patient's bed. 



origin from this source by post-mortem examination. Some attribute 
all such cases to embolism, others think that they may be the results 
of primary septicemic inflammation. It has been proved by Weber 
that minute infected emboli may pass through the lung capillaries ; 
and this disposes of one argument against the embolic theory, based 
on the supposed impossibility of their passage. It is probable that 
both causes may operate, and that localized inflammations occurring a 
short time after delivery are directly produced by the infected blood, 
while those occurring after the lapse of some time, as in the second or 
third week, depend upon embolism. 



644 



THE PUERPERAL STATE. 



Fig. 211. 



Description of the Disease. — From what has been said as to the 
mode of infection in puerperal septicemia, and as to the very various 
pathological changes which accompany it, it will not be a matter of 
surprise to find that the symptoms are also very various in different 
cases. This can readily be explained by the amount and virulence of 

the poison absorbed, the channels of 
infection, and the organs which are 
chiefly implicated ; but it renders it 
very difficult to describe the disease 
satisfactorily. 

The symptoms generally show 
themselves within two or three days 
after delivery. As infection most 
often occurs during labor, or in cases 
which are saprseniic within a short 
time afterward, and before the lesions 
of continuity in the generative tract 
have commenced to cicatrize, it can 
be understood why septicaemia rarely 
commences later than the fourth or 
fifth day. 

In the great majority of cases the 
disease begins insidiously. There 
are, generally, some chilliness and 
rigor, but by no means always, and 
even when present they frequently 
escape observation or are referred to 
some transient cause. The first symp- 
tom which excites attention is a rise 
in the pulse, which may vary from 
100 to 140 or more, according to the 
severity of the attack ; and the ther- 
mometer will also show that the tem- 
perature is raised to 102°, or, in bad 
cases, even to 104° or 106°. Still it 
must be borne in mind that both the 
pulse and temperature may be in- 
creased in the puerperal state from transient causes, and do not of 
themselves justify the diagnosis of septicaemia. 

In the more intense class of cases, in which the whole system seems 
overwhelmed with the severity of the attack, the disease progresses 
with great rapidity, and often without any appreciable indication of 
local complication. The pulse is very rapid, small, and feeble, varying 
from 120 to 140, and there is generally a temperature of 103° to 104°. 
In the worst form of cases the temperature is steadily high without 
marked remissions (see Figs. 209, 214, and 215). There maybe little 
or no pain, or there may be slight tenderness on pressure over the 
abdomen or uterus ; and, as the disease progresses, the intestines get 
largely distended with flatus, so that intense tympanites often forms a 
most distressing symptom. The countenance is sallow, sunken, and 



TIME 


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PULSE 




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120 


140 


80 


80 


80 


DATE 


22 


23 


24 


25 


26 


27 


28 



Mrs. P., aged twenty-four years; labor 
natural ; confined May 22, 18S0. A piece of 
decomposed membrane the size of hand 
wash ed out of her uterus at first intra-uterine 
injection; rapid recovery. 



P l' KRPERAL SEPTICEMIA, 



645 



has a very anxious expression. As a rule, intelligence Is unimpaired, 
and this may be tin 4 case even in the worst forms of the disease, and 
up to the period of death. At other times there is a good deal of low 
muttering delirium, which often occurs at night alone, and alternates 
with intervals of complete consciousness, hut is occasionally intensified 
tor a short time into a more acute form. Diarrhoea and vomiting are of 
very frequent occurrence ; by the latter, dark, grumous, coffee-ground 
substances are ejected. The diarrhoea is occasionally very profuse and 
uncontrollable ; in mild cases it seems to relieve the severity of the 

Fig. 212. 



TIME 


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84 


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116 


96 


120 


88 


78 








DATE 


S 


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8 


9 


10 


11 


12 


13 


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15 


16 


17 


18 


19 



Mrs. X., aged twenty 
offensive ; 2 



■two years ; confined Thursday, May 6, 1880. Forceps. Lochia from the first 
, small piece of memhrane was probably left in utero. 



symptoms. The tongue is moist and loaded with sordes ; but some- 
times it gets dark and dry, especially toward the termination of the 
disease. The lochia are generally suppressed or altered in character, 
and sometimes they have a highly offensive odor, especially when the 
disease is of the so-called autogenetic type. The breathing is hurried 
and panting, and the breath itself has a characteristic, heavy, sweetish 
odor. The secretion of milk is often, but not always, arrested. 

Duration. — AVith more or less of these symptoms the case goes on ; 
and when it ends fatally it generally docs so within a week, the fatal 
termination being indicated by more weakness, rapid, thread-like, or 
intermittent pulse, marked delirium, great tympanites, and sometimes 



646 



THE PUERPERAL STATE. 



a sudden fall of temperature, until at last the patient sinks with all the 
symptoms of profound exhaustion. 

In milder cases similar symptoms, variously modified and combined, 
are present. It is seldom that two precisely similar cases are met with ; 
in some the rapid, weak pulse is most marked ; in others abdominal 
distention, vomiting, diarrhoea, or delirium. 

Local complications variously modify the symptoms and course of 
the disease. The most common is peritonitis, so much so that with 
some authors puerperal fever and puerperal peritonitis are synonymous 



Fig. 213. 



TIME 


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DAY OF 
DIS. 








1ST. 


2nd. 


3RD. 


4TM. 


5TH. 


6TH. 


7TH. 


8TH. 


9TH- 


10th 


11TH 


12TH. 


13TH 


14th 


15TH 


16th. 


17th. 




PULSE 


\73 


\90 


\ioo v 


\ 1 3 ' 
12\ 


\l30 
I28\ 


128\ 


I25\ 


100\ 


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120\ 


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DATE 


26 


27 


28 


29 


30 


31 


Augl 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 



Mrs. 



aged twenty-five years ; recovery. Confined July 26, 1879. 7.40 p.m. 



terms. Here the first symptom is severe abdominal pain, commencing 
at the lower part of the abdomen, where the uterus is felt enlarged and 
tender. As the abdominal pain and tenderness spread, the sufferings of 
the patient greatly increase, the intestines become enormously distended 
with flatus, and the breathing is entirely thoracic, in consequence of 
the upward displacement of the diaphragm and the fact that the 
abdominal muscles are instinctively kept as much in repose as possible. 
The patient lies on her back with her knees drawn up and sometimes 
cannot bear the slightest pressure of the bedclothes. There is gener- 
ally much vomiting, and often severe diarrhoea. The temperature 
generally ranges from 102° to 104°, or even 106°, and is subject to 



PUERPERAL SEPTICEMIA. 



647 



occasional exacerbations and remissions, possibly depending on fresh 
absorption of septic matter (see Figs. 210, 21*2, and 213). The ease; 
generally lasts for a week or more, the symptoms going on from bad 
to worse, and the patient dying exhausted. D'Espine points out that 
rigors, with exacerbations of the general symptoms, not unfrequently 
occur about the sixth or seventh day, which he attributes to fresh 
systemic infection from fetid pus in the peritoneal cavity. It must 
not be supposed that all these symptoms are necessarily present when 
the peritonitic complication exists. Pain is especially often entirely 
absent, and I have seen cases in which post-mortem examination 

Fig. 214. 



TIME 


m|e 


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DAY OF 
DIS. 


1ST. 


2nd. 


3RD. 


4TH. 


5TH. 


6th. 


7th. 


8TH. 


9TH. 


10TH. 


11th 


12th. 


13TH. 


14th. 


15TH 


16TH 


17TH. 


18TH. 


19TH 


20th. 


PULSE 




130 








120 




150 








TOO 


















DATE 


Aug6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 



Mrs. M. K., aged twenty-one years ; infection believed to be due to scarlatina. 
Confined August 5, 1878 ; recovery. 



proved the existence of peritonitis in a very marked degree, in which 
pain was entirely absent. Sometimes the pain is only slight and 
amounts to little more than tenderness over the uterus. 

Symptoms of other local complications are characterized by their 
own special symptoms: thus, pneumonia by dyspnoea, cough, dulness, 
etc. : pericarditis by the characteristic rub ; pleurisy by dulness on per- 
cussion; kidney affection by albuminuria and the presence of casts; 
liver complication by jaundice; and so on. 

Pysemic Forms of the Disease. — The course of the disease is not 
always so intense and rapid, being in some cases of a more chronic 
character and lasting many weeks. The symptoms in the early stage 



618 THE PUERPERAL STATE. 

are often indistinguishable from those already described, and it is 
generally only after the second week that indications of purulent infec- 
tion develop themselves. Then we often have recurrent and very 
severe rigors, with marked elevations and remissions of temperature. 
At the same time there is generally an exacerbation of the general 
symptoms, peculiar yellowish discoloration of the skin, and occasionally 
well-developed jaundice. Transient patches of erythema are not un- 
commonly observed on various parts of the skin, and such eruptions 
have often been mistaken for those of scarlet fever or other zymotic 
disease. Localized inflammations and suppuration may rapidly follow. 
Amongst the most common are inflammation or even suppuration of 
the joints — the knees, shoulders, or hips — which is preceded by diffi- 
culty of movement, swelling, and very acute pain. Large collections 
of pus in various parts of the muscles and connective tissues are not 
rare. Suppurative inflammation may also be found in connection 
with many organs, as in the eye, in the pleura, pericardium, or lungs ; 
each of which will, of course, give rise to characteristic symptoms, 
more or less modified by the type of the disease and the intensity of 
the inflammation. 

Puerperal Malarial Fever. — There is a peculiar form of febrile 
disturbance which sometimes occurs in the puerperal state, and which 
is apt to be confounded with septicaemia, to which attention was 
specially directed by the late Fordyce Barker, 1 under the name of 
"puerperal malarial fever," It is specially apt to be met with in 
women who have been exposed to malarial poison duriug their former 
lives, the recurrence of the fever beiug probably determined by the 
puerperal state. Of this I have seen several very well-marked ex- 
amples in ladies who had formerly contracted fever and ague in India. 
One of my patients who has been long in India, and suffered from 
intermittent fever for years, is invariably attacked with it after 
delivery, and herself warned me of the fact the first time I attended 
her. The diagnosis is not always easy. Barker insisted on the fact 
that puerperal malarial fever generally commences after the fifth day 
of delivery, while septicaemia almost always does so before that time. 
In the malarial fever, moreover, the intermissions are much more 
marked, while there are frequently recurring chills or rigors, which is 
not the case in septicaemia. 

Treatment. — In considering the all-important subject of treatment, 
the views of the practitioner are naturally biased by the theory he has 
adopted of the nature of the disease. If that here inculcated be cor- 
rect, the indications we have to bear in mind are : first, to discover, if 
possible, the source of the poison, in the hope of arresting further septic 
absorption ; secondly, to keep the patient alive until the effects of the 
poison are worn off; and thirdly, to treat any local complication that 
may arise. 

The first is likely to be of great importance in cases of saprseinia, as 
fresh quantities of septic matter may be from time to time absorbed. 
We, fortunately, are in possession of a powerful means of preventing 

i "Puerperal Malarial Fever," Amer. Journ. of Obstet, 1880, vol. xiii. p. 271. 



PUERPERAL SEPTICEMIA. 



649 



further absorption by the application of antiseptics to the interior of 
the uterus and to the canal of the vagina. 'This is especially valuable 
when the existence of decomposing coagula or other sources of septic 
matter is suspected in the uterine cavity, or when offensive discharges 

Fig 215. 



TIME 


M 


E 


M 


\ 


u 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 












































U07 
job* 
105 
104 

s I0 3 

i 

z 

I 102 

2 

X c 
= 101 

< 

c 

99 

NORM. TEM 
OF BODY 


















































































































































































< 






































o 










































































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Mrs. B., aged twenty-nine years ; confined March 29 ; died April 7, 1879. 

tire present. Disinfection is readily accomplished by washing out the 
uterine cavity, at least twice daily, by means of a Higginson syringe 
with a long vaginal pipe attached. 1 The results are sometimes very 
remarkable, the threatening symptoms rapidly disappearing and the 
temperature and pulse falling so soon after the use of the antiseptic 



1 My colleague, Dr. Hayes, has invented a silver tube for the purpose of administering such intra- 
uterine injections (Fig. 2i6), which answers its purpose admirably. The numerous apertures at its 

Fig. 216. 




Hayes's tube for intra-uterine injections. 

•extremity allow of a number of minute streams of fluid being thrown out in the form of a spray 
over the interior of the uterus, the complete bathing of its surface and washing out of its cavity 
being thus insured. It is, moreover, introduced more easily than the ordinary vaginal pipe, and 
can be attached to a Higginson syringe. 



650 



THE PUERPERAL STATE. 



injections as to leave no doubt of the beneficial effects of the treatment* 
I cannot better illustrate the advantages of this treatment than by the 
temperature chart (Fig. 217), which is from a case which came under 
my observation in the outdoor practice of King's College Hospital. 
It was that of a healthy 'woman, thirty-six years of age, who had an 
easy and natural labor. Nothing remarkable was observed until 
the third day after delivery, when the temperature was found to be 
slightly increased. On the morning of the eighth day the temperature 
had risen to 105.8°. She was delirious, with a rapid, thready pulse, 

Fig. 217. 



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clammy perspiration, tympanitic abdomen, and her general condition 
indicated the most urgent danger. On vaginal examination a piece of 
compressed and putrid placenta was found in the os. This was 
removed by my colleague, Dr. Hayes, and the uterus thoroughly 
Avashed out with Condy's fluid and water. The same evening the 
temperature had sunk to 99° and the general symptoms were much 
improved. The next day there was a slight return of offensive dis- 
charge, and an aggravation of the symptoms. After again washing 
out the uterus the temperature fell, and from that date the patient con- 
valesced without a single bad symptom. (See Fig. 211.) 

This is a very well marked example of the value of local antiseptic 
treatment, and I have seen many cases of the same kind. It should, 
therefore, never be omitted in all cases in which the presence of decom- 
posing structures within the uterus is suspected ; and, indeed, even 
when there is no reason to suspect the presence of a local focus of 
infection, the use of antiseptic lotions is advisable as a matter of pre- 
caution, since it can do no harm and is generally comforting to the 
patient. Various antiseptics may be used, such as a weak solution of 
carbolic acid, 1 : 50, tincture of iodine dropped into warm water until 
it has a pale sherry color, or a solution of perchloride of mercury of 
the strength of 1 : 2000. Of these, the perchloride of mercury solution 
is the most effective germicide, and Koch's experiments have conclu- 
sively proved that it is the only recognized antiseptic which can be 
relied upon for destroying the spores of micro-organisms after a single 
application. As, however, there is a possibility that a too free and 
incautious use of the corrosive sublimate might prove poisonous, it 



PUERPERAL SEPTICEMIA. 651 

would be well that such infra-uterine injections should not be stronger 
than 1 : 2000, and that they should be practised by the medical man 
himself, the quantity for such irrigation not exceeding two quarts. 1 

One or other of these may be advantageously used alternately — one in 
the morning, the other in the evening. Occasionally I have employed 
a 1 : 50 solution of carbolic acid, with about 5 grains to the ounce of 
iodoform suspended in it. This has the advantage of not only being a 
powerful antiseptic, but of acting more continuously in consequence of 
the powdered iodoform remaining partially attached to the uterine 
walls; or, as some have advised, an iodoform bougie 2 may be placed 
in the uterine cavity, or powdered iodoform insufflated through the 
cervix. The nozzle of the syringe should be guided well through the 
cervix, and the cavity of the uterus thoroughly washed out until the 
fluid that issues from the vagina is no longer discolored. As the os is 
always patulous, there is no risk of producing the troublesome symp- 
toms of uterine colic, which occasionally follow the use of intra-uterine 
injections in the unimpregnated state. It is quite useless to intrust 
the injection to the nurse, and it should be performed at least twice 
daily by the practitioner himself, in all cases in which the discharges 
are offensive. It is not advisable, however, that such injections should 
be used indiscriminately, since they are not entirely free from risk 
and may even be the means of introducing fresh septic matter into the 
uterine cavity. It has been pointed out 3 that sometimes the intra- 
uterine injection itself produces rigors and other nervous troubles. I 
am certain that this observation is correct, and I have myself more 
than once seen a severe rigor rapidly follow its administration. In 
any case it is useless to continue the use of intra-uterine injections for 
more than one or two days ; they may be serviceable in the earlier 
stages of the disease, but when systemic infection has occurred they 
cease to be of use. The vulva should in all cases be carefully inspected 
with the view of ascertaining if the source of infection be not some 
local slough or necrotic ulcer about the perineum or orifice of the 
vagina, in which case its surface should be freely covered with iodo- 
form. I have seen more than one instance in which this simple 
procedure has sufficed to cut short symptoms of a very threatening 
character. 

Curetting- the Uterine Cavity. — Curetting 4 the interior of the 
uterus has been strongly recommended and largely practised, especially 
in Vienna. It may obviously be valuable in cases in which retention of 
portions of the placenta or membranes is suspected, or in which a 
highly offensive discharge leads us to think that a necrosed condition 
of the decidua may exist. The patient is placed in the semi- prone 
position, the vagina irrigated with a sublimate solution and the ante- 
rior lip of the cervix drawn down with a volsella, and the endometrium 
thoroughly scraped with a blunt curette. The cavity of the uterus is 

1 Herff: "L'eber Ursachen und Verhiitung der Sublimat-Vergiftung," etc., Arch. f. Gvnak., 
1885, Bd. xxv. S. 4ST. 

2 These may be made of gam arabic and glycerin, about two and a half inches in length, each 
containing 90grains of iodoform. 

3 Mangin : '-Quelques accidents provoques par les injections intra-uterines," Xouv. Arch. 
d'Obstet. et de Gyn., 1888, p. 3-i. 

4 See Weiss on " Curettement in Puerperal Septicemia," Amer. Journ. of Obstet , August, 1S92. 



652 THE PUERPERAL STATE. 

subsequently well swabbed out with tincture of iodine. It can be 
readily understood that such a procedure is more thorough and com- 
plete than intra-uterine injection, and there can be no objection to a 
careful use of it in hands tolerably expert in obstetric manipulations. 
It must, however, be only practised in exceptional cases, and with 
great caution, since any roughness might seriously injure the uterine 
structures. 

Administration of Food and Stimulants. — In a disease char- 
acterized by so marked a tendency to prostration, the importance of 
sustaining the vital powers by an abundance of easily assimilated nour- 
ishment cannot be overrated. Strong beef-tea or other forms of animal 
soup, milk, alone or mixed either with lime- or soda-water, and the 
yelk of eggs, beat up with milk and brandy, should be given at short 
intervals and in as large quantities as the patient can be induced to 
take ; and the value of thoroughly efficient nursing will be especially 
apparent in the management of this important part of the treatment. 
As there is frequently a tendency to nausea the patient may resist the 
administration of food, and the resources of the practitioner will be 
taxed in administering it in such form and variety as will prove least 
distasteful. Generally speaking, not more than one or two hours should 
be allowed to elapse without some nutriment being given. The amount 
of stimulant required will vary with the intensity of the symptoms and 
the indications of debility. Generally, stimulants are well borne, prove 
decidedly beneficial, and require to be given pretty freely. In cases 
of moderate severity a tablespoonful of good old brandy or whiskey 
every four hours may suffice ; but when the pulse is very rapid and 
thready, when there is much low delirium, tympanites, or sweating 
(indicating profound exhaustion), it may be advisable to give them in 
much larger quantities and at shorter intervals. The careful practi- 
tioner will closely watch the effects produced, and regulate the amount 
by the state of the patient rather than by any fixed rule ; but in severe 
cases eight or twelve ounces of brandy, or even more, in the twenty-four 
hours may be given with decided benefit. 

Venesection, both general and local, was long considered a sheet- 
anchor in this disease. Modern views are, however, entirely opposed 
to its use ; and in a disease characterized by so profound an alteration 
of the blood and so much prostration, it is too dangerous a remedy to 
employ, although it is possible that it might alleviate temporarily the 
severity of some of the symptoms, especially in cases in which perito- 
nitis is well marked and much local pain and tenderness are present. 

Medicinal Treatment. — The rational indications in medical treat- 
ment are to lessen the force of the circulation as much as is possible 
without favoring exhaustion, and to diminish the temperature. 

For the former purpose Barker strongly advocated the use of vera- 
truin viride, in doses of five drops of the tincture every hour, until the 
pulse falls to below 100, when its effects are subsequently kept up by two 
or three drops every second hour. Of this drug I have no personal ex- 
perience ; but I have extensively used minute doses of tincture of aconite 
for the same purpose, and, when carefully given, I believe it to be a 
most valuable remedy. The way I have administered it is to give a 



PUERPERAL SEPTICEMIA. 653 

single drop of the tincture, at first every half-hour, increasing the 
interval of administration according to the effect produced. Generally, 
after giving four or five doses at intervals of half an hour, the pulse 
begins to fall, and afterward a few doses at intervals of one or two 
hours will suffice to prevent the heart's action rising to its former 
rapidity. The advantage of thus modifying the cardiac action, with 
the view of preventing excessive waste of tissue, cannot be questioned. 
It is evident that so powerful a remedy must not be used without the 
most careful supervision, for, if continued too long, or given at too 
frequent intervals, it may unduly depress the circulation and do more 
harm than good. It is necessary, therefore, that the practitioner 
should constantly watch the effect of the drug, and stop it if the pulse 
become very weak, or if it intermit. It is most likely to be useful at 
au early stage of the disease before much exhaustion is present, and 
then only when the pulse is of a certain force and volume. Barker 
says of the veratrum viride, what is also true of aconite, that " it 
should not be given in those cases in which rapid prostration is man- 
ifested by a feeble, thread-like, irregular pulse, profuse sweats, and 
cold extremities." 

The Reduction of Temperature must form an important part of 
our treatment, and for this purpose many agents are at our disposal. 

Quinine in large doses, of from 10 to 30 grains, has been much 
used for this purpose, especially in Germany. After its exhibition 
the temperature frequently falls one or two degrees. It may be given 
morning and evening. Unpleasant head-symptoms, deafness, and 
ringing in the ears often render its continuance for a length of time 
impossible. These may, how r ever, be much lessened by the addition 
of 10 to 15 minims of hydrobromic acid to each dose. 

Antipyrine in doses of 20 grains every three or four hours some- 
times proves very efficacious ; but, as it is apt to depress, it should be 
combined with some stimulant, such as 30 minims of sal -volatile. 

Salicylic acid, in closes of from 10 to 20 grains, or the salicylate of 
soda in the same doses, is a valuable antipyretic which I have found 
on the whole more manageable than quinine. Under its use the 
temperature often falls considerably in a short space of time. It is, 
however, apt to depress the circulation, and thus requires to be care- 
fully watched while it is being administered ; and should the pulse 
become very small and feeble, it should be discontinued. 

In some cases, especially when the fever has assumed a remittent 
type, I have administered with marked benefit a drug which is of 
high repute in India in the w r orst class of malarious remittent fevers, 
and the almost marvellous effects of which in such cases I had myself 
witnessed in India many years ago. This is the so-called Warburg's 
tincture, the value of which has been testified to by many high authori- 
ties, among whom I may mention Dr. Maclean, of Netley, Dr. Broad- 
bent, and Sir Alexander Armstrong, the Director-General of the 
Medical Department of the Navy, who informs me that it is now r sup- 
plied to all Her Majesty's ships in the tropics, because it is found to 
be of the utmost value in cases in which quinine has little or no effect. 
Recently its composition has been made public by Dr. Maclean. The 



654 THE PUERPERAL STATE. 

basis is quinine, in combination with various aroruatics and bitters, 
some of which probably intensify its action. Be this as it may, the testi- 
mony in favor of the antipyretic action of the remedy is very strong. 
I have found its exhibition followed by a profuse diaphoresis (this 
being its almost invariable effect), and sometimes a rapid amelioration 
of the symptoms. In other cases in which I have tried it, like every- 
thing else, it has proved of no avail. Of its use in ten malarial cases 
above alluded to, Dr. Fordyce Barker says : " For nearly two years 
past, in those cases where the stomach will tolerate it, I have found 
Warburg's tincture much more effective and speedy in producing the 
results desired than the largest doses of quinine." l 

Application of Cold. — Cold may be advantageously tried in suit- 
able cases. The simplest mode of using it is by Thornton's ice-cap, 
by which a current of cold water is kept continuously running round 
the head. This has been found of great value in pyrexia after ovari- 
otomy, and I have also found it useful as a means of reducing tempera- 
ture in puerperal cases. It is a comforting application and gives great 
relief to the throbbing headache, which often causes much suffering. 
Under its use the temperature often falls two or more degrees, and it 
is easily continued day and night. 

In very serious cases, when the temperature reaches 105° or upward, 
the external application of cold to the rest of the body may be tried. 
I have elsewhere related 2 a case of puerperal septicaemia with hyper- 
pyrexia, the temperature continuously ranging over 105°, in which I 
kept the patient for eleven days nearly constantly covered with cloths 
soaked in iced water, by which means only was the temperature kept 
within moderate bounds and life preserved. But this method of treat- 
ment is excessively troublesome, and is in no way curative. It is 
only of use in moderating the temperature when it has reached a point 
at which it could not continue long without destroying the patient. 
I should, therefore, never think of employing it unless the temperature 
was over 105°, and then only as a temporary expedient, requiring 
incessant watching, to be desisted from as soon as the temperature had 
reached a more moderate height. It is clearly impossible to place a 
puerperal patient in a bath, as is practised in hyperpyrexia associated 
with acute rheumatism or typhoid fever. The same effect may, how- 
ever, be obtained by placing her on mackintosh sheeting, or still better 
on a water-bed, into which cold water is run from time to time, and 
covering the body with towels soaked in ice-water, which are fre- 
quently renewed by the attendant nurses. During the application the 
temperature should be constantly taken, and as soon as it has fallen 
to 101° the cold application should be discontinued. 

Administration of Turpentine. — Amongst other remedies which 
have been used is turpentine, which was highly thought of by the 
Dublin school. In cases with much tympanitic distention, and a small 
weak pulse, it is sometimes of unquestionable value, and it probably 
acts as a strong nervine stimulant. Given in doses of 15 to 20 minims 

1 Op. cit., p. 278. 

2 " A Lecture on a Case of Puerperal Septicaemia with Hyperpyrexia, treated by the Continuous 
Application of Cold," Brit. Med. Journ., 1877, vol. ii. p. 687. 



PUERPERAL SEPTICAEMIA 655 

rubbed up with mucilage, it can generally be taken in spite of its 
nauseous taste. 

Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, 
have often been employed as eliminants of the poison. The former 
are strongly recommended by Schroeder and other German authorities, 
and in England they were formerly amongst the most favorite 
remedies, and there is a general concurrence of opinion amongst our 
older writers as to their value. Iu the first volume of the Obstetrical 
Journal there is a paper by Mr. Morton, in which this practice is 
strongly advocated, and some interesting cases are recorded in which 
it apparently acted well. He administers calomel in doses of 3 or 4 
grains with compound extract of colocynth, so as to keep up a free 
action of the bowels. It seems quite reasonable, when there is con- 
stipation, to promote a gentle action of the bowels by some mild 
aperient ; but, bearing in mind that severe and exhausting diarrhoea is 
a common accompaniment of the disease, I should myself hesitate to 
run the risk of inducing it artificially, especially as there is no proof 
whatever that septic matter can really be eliminated in this way. At 
the commencement of the disease, however, I have often given one or 
two aperient doses of calomel with decided benefit. 

Internal Antiseptic Remedies. — It is possible that further research 
will give us some means of counteracting the septic state of the blood ; 
and the sulphites and carbolates have been given for this purpose, but 
as yet with no reliable results. 

The tincture of the perchloride of iron naturally suggests itself, 
from its well-known effects in surgical pyaemia. In the less intense 
forms of the disease, especially when local suppurations exist, it is 
certainly useful, and may be given in doses of 10 to 20 minims every 
three or four hours. In very acute cases other remedies are more 
reliable, and the iron has the disadvantage of not unfrequently causing 
nausea or vomiting. 

When restlessness, irritation, and want of sleep are prominent 
symptoms, sedatives may be required. Under such circumstances 
opiates may be given at night, and Battley's solution, nepenthe, or the 
hypodermic injection of morphia is the form which answers best. 

Treatment of Local Complications. — Pain, tenderness, and local 
complications must be treated on general principles. The distress 
from them is most experienced when peritonitis is well marked. Then, 
warm and moist applications, in the form of poultices or fomentations, 
are very useful. Relief is also sometimes obtained from turpentine 
stupes, and when the tympanites is distressing, turpentine enemata are 
very serviceable. I have found the free application over the abdomen 
of the flexible collodium of the Pharmacopoeia decidedly useful in alle- 
viating the suffering from peritonitis. 

Coeliotomy in cases of puerperal peritonitis lias been discussed and 
practised within the last few years. 1 The subject is too new, and, as 
yet, experience far too small, to justify any dogmatic opinion as to its 

1 See Maury, " The Indications for Coeliotomy in Puerperal Fever," and Hirst, " The Position of 
Abdominal Section in the Treatment of Septic Peritonitis after Childbirth," Trans, of the Amer. 
Gyn. Soc, 1891. 



656 THE PUERPERAL STATE. 

merits or demerits. So far as existing evidence seems to show, the 
successful cases have been examples of localized pus deposits, more in 
the nature of pelvic peritonitis, or. in a few cases, of general sup- 
purative peritonitis. In the latter class the operation has been per- 
formed a considerable time after delivery, such as six weeks, but cases 
of this kind cannot with propriety be called true puerperal septicaemia. 
The few cases reported in which coeliotomy has been performed soon 
after the development of septic symptoms appear all to have ended 
fatally. This is exactly what one would have a priori expected. In 
acute septic infection, which is a general and not a local disease, there 
are. it is true, very often marked symptoms of peritoneal disease, such 
as tenderness, immense distention, and the like ; but this is one only of 
many local phenomena. To open the abdomen in such cases would be 
rash in the extreme, and a most hopeless procedure ; it might even be 
impossible to return the enormously inflated intestines. It has been 
said that cceliotomy to be of use in cases of this kind must be done 
early, but it is to be remembered that in the early stages of septicaemia 
the symptoms are not well marked. The hope of cutting them short 
has not been abandoned, and it would lead to deplorable results if 
advice of this kind should lead to opening the abdomen of puerperal 
patients as soon as suspicious symptoms arose. In the former class, 
however, it is certain that in well-selected cases cceliotomy. washing 
out of the abscess cavity or peritoneum, and drainage, offer by far the 
best prospects of recovery. 

Such are the remedies most used in this disease. It is needles- to 
say that it is quite iinpos-ible to lay down fixed rules for the manage- 
ment of any individual case; and it is obvious that, if puerperal septi- 
caemia be not a special and distinct disease, its judicious treatment must 
depend on the general knowledge of the attendant and on a careful 
study of the symptoms each separate case presents. 



CHAP TEE VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results. — Under the head of 
thrombosis we may class several important diseases connected with the 
puerperal state, which have received far less attention than they deserve. 
It is only of late years that some, we may probably safely say the 
majority, of those terribly sudden deaths which from time to time occur 
after delivery have been traced to their true cause, viz.. obstruction ol 
the right side of the heart and pulmonary arteries from a blood-clot, 
either carried from a distance or. as I shall hope to show, formed in 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 657 

situ. Although the result and, to a great extent, the symptoms, are 
identical in both, still a careful oonsideratioo of the history of these 
two classes of cases tends to show that in their production they are 
distinct, and that they ought not to be confounded. In the former we 
have primarily a clotting of blood in some part of the peripheral 
venous system, and the separation of a portion of such a thrombus 
due to changes undergone during retrograde metamorphosis tending to 
it- eventual absorption. In the Latter we have a local depositing of 
fibrin, the result of blood changes consequent on pregnancy and the 
puerperal state. The formation of such a coagulum in vessels the 
complete obstruction of which is incompatible with life, explains the 
fatal results. "When, however, a coagulum chances to be formed in 
more distant parrs of the circulation, the vital functions are not imme- 
diately interfered with, and we have other phenomena occurring, due 
to the obstruction. The disease known as phlegmasia dolens, 1 shall 
presently attempt to show, is one result of blood-clot forming in periph- 
eral vessels. But from the evident and tangible symptoms it pro- 
duces, it has long been considered an essential and special disease, and 
the general blood dyscrasia which produces it, as well as other allied 
states, has not been studied separately. I shall hope to show that all 
these various condition-, dissimilar as they at first sight appear, are 
very closely connected, and that they are in fact due to a common 
cause ; and thus, I think, we shall arrive at a clearer and more correct 
idea of their true nature than if we looked upon them as distinct and 
separate affections, as has been commonly done. I am aware that in 
phlegmasia dolens, the pathology of which has received perhaps more 
study than that of almost any other puerperal affection, something 
beyond simple obstruction of the venous system of the affected limb is 
probably required to account for the peculiar tense and shining swelling 
which is so characteristic. Whether this be an obstruction of the 
lymphatics, as Dr. Tilbury Fox and others have maintained with much 
show of reason, or whether it is some as yet undiscovered state, further 
investigation is required to show. But it is beyond any doubt that the 
important and essential part of the disease is the presence of a thrombus 
in the vessels ; and I think it will not be difficult to prove that in its 
causation and history it is precisely similar to the more serious cases in 
which the pulmonary arteries are involved. 

It will be well to commence the study of the subject by a considera- 
tion of the conditions which, in the puerperal state, render the blood 
so peculiarly liable to coagulation, and we may then proceed to discuss 
the symptoms and results of the formation of coagula in various parts 
of the circulatory system. 

Conditions -which Favor Thrombosis. — The researches of Vir- 
chow, Benjamin Ball, Humphry, Richardson, and others have rendered 
us tolerably familiar with the conditions which favor the coagulation 
of the blood in the vessels. These are chiefly : 1. A stagnant or 
arrested circulation ; as, for example, when the blood coagulates in the 
veins which draw blood from the gluteal region in old and bedridden 
people, or, as in some forms of pulmonary thrombosis, in which the 
clots in the arteries are probably the result of obstruction in the circu- 

42 



658 THE PUERPERAL STATE. 

lation through the lung-capillaries, as in certain cases of emphysema, 
pneumonia, or pulmonary apoplexy. 2. A mechanical obstruction 
around which coagula form, as in certain morbid states of the vessels ; 
or, a better example still, secondary coagula which form around a 
travelled embolus impacted in the pulmonary arteries. 3. And most 
important of all, in which the coagulation is the result of some morbid 
state of the blood itself. Examples of this last condition are fre- 
quently met with in the course of various diseases, such as rheumatism 
or fever, in which the quantity of fibrin is increased and the blood 
itself is loaded with morbid material. Thrombosis from this cause is 
of by no means infrequent occurrence after severe surgical operations, 
especially such as have been attended with much hemorrhage, or when 
the patient is in a weak and anaemic condition. This has been specially 
dwelt upon, as a not un frequent source of death after operation, by 
Fayrer and other surgeons. 1 

Coagulation in the Puerperal State. — But little consideration is 
required to show why thrombosis plays so important a part in the 
puerperal state, for there most of the causes favoring its occurrence 
are present. Probably there is no other condition in which they exist 
in so marked a degree, or are so frequently combined. The blood 
contains an excess of fibrin, which largely increases in the latter 
months of utero-gestation, until, as has been pointed out by Andral 
and Gavarret, it not unfrequently contains a third more than the 
average amount present in the non-pregnant state. As soon as delivery 
is completed, other causes of blood-dyscrasia come into operation. 
Involution of the largely hypertrophied uterus commences, and the 
blood is charged with a quantity of effete material, which must be 
present in greater or less amount until that process is completed. It 
is an old observation that phlegmasia dolens is of very common occur- 
rence in patients who have lost much blood during labor. Thus Dr. 
Leishman says: "In no class of cases has it been so frequently 
observed as in women whose strength has been reduced to a low ebb 
by hemorrhage either during or after labor, and this, no doubt, 
accounts for the observation made by Merriman, that it is relatively a 
common occurrence after placenta prsevia." 2 An examination of the 
cases in which death results from pulmonary thrombosis shows the 
same facts, as in a large proportion of them severe post-partum heni- 
orrhag has occurred. The exhaustion following the excessive losses 
so common after labor must of itself strongly predispose to throm- 
bosis and, indeed, loss of blood has been distinctly pointed out by 
Richardson to be one of its most common antecedents. " There is," 
he observes, " a condition which has been long known to favor coagu- 
lation and fibrinous deposition. I mean loss of blood and syncope or 
exhaustion during impoverished states of the body." 

Since, then, so many of the predisposing causes of thrombosis are 
present in the puerperal state, it is hardly a matter of astonishment 
that it should be of frequent occurrence or that it should lead to con- 
ditions of serious gravity. And yet the attention of the profession 

1 Edin. Med. Journ., March, 1861 ; Indian Annals of Med., July, 1887. 

2 Leishman : System of Obstetrics, p. 720. 2nd edition, 1876. 



FLERFERAL VENOUS THROMBOSIS AND EMBOLISM. 659 

has been for the most part limited to a study of only one of the results 
of this tendency to blood-clotting after delivery, no doubt because of its 
comparative frequency and evident Bymptoms. True, the balance of 
professional opinion has lately held that phlegmasia dolens is chiefly 

the result of some morbid condition of the bl L producing plugging 

of the vein-; hut the wider view which I am attempting to maintain, 
which would bring this disease into close relation with the more rarely 
observed, hut infinitely important, obstructions of the pulmonary 
arteries, has scarcely, if at all. been insisted on. Doubtless further 
investigation will show that it is not in these parts of the venous 
system alone that puerperal thrombosis occurs; but the symptoms and 
effects of venous obstruction elsewhere, important though they may 
be, are unknown. 

Distinction between Thrombosis and Embolism. — I propose, 
then, to describe the symptoms and pathology of blood-clot in the 
right side of the heart and pulmonary artery. It may be useful here 
to repeat that this is essentially distinct from embolism of the same 
parts. The latter is obstruction due to the impaction of a separated 
portion of a thrombus formed elsewhere, and for its production it is 
es-eiitial that thrombosis should have preceded it. Embolism is. in 
fact, an accident of thrombosis, not a primary alfection. The condi- 
tion we are now discussing I hold to be primary, precisely similar in 
its causation to the venous obstruction which, in other situations, gives 
rise to phlegmasia dolens. 

At the threshold of this inquiry we have to meet the objection 
started by several who have written on this subject, 1 that spontaneous 
coagulation of the blood in the right side of the heart and pulmonary 
arteries is a mechanical and physiological impossibility. This was 
the view of Virchow, who, with his followers, maintained that when- 
ever death from pulmonary obstruction occurred, an embolns was of 
necessity the starting-point of the malady and the nucleus round 
which secondary deposition of fibrin took place. Virchow holds that 
the primary factor in thrombo-i- is a stagnant state of the blood, and 
that the impulse imparted to the blood by the right ventricle is of 
itself sufficient to prevent coagulation. It is to be observed that these 
objections are purely theoretical. Without denying that there is con- 
siderable force in the arguments adduced. I think that the clinical 
history of these cases strongly favors the view of spontaneous coagu- 
lation ; and I would apply to the theoretical objections advanced the 
argument used by one of their strongest upholders with regard to 
another disputed point: "Je prefere laisser la parole aux fait?, car 
devant eux la theorie s'incline." - 

The anatomical arrangement of the pulmonary arteries shows how 
spontaneous coagulation may be favored in them ; for, as Humphry 
has pointed out. 3 ""the artery breaks up at once into a number of 
branches, which radiate from it. at different angles to the several parts 
of the lungs. Consequently a large extent of surface i- presented to 

1 See especially Bertin : Des Embolies, p. 46 et aeq. 

- Btrtin Des Embolies. p. 149. 

3 Humphry : on the Coagulation of the Blood in the Venous System during Life. 



660 THE PUERPERAL STATE. 

the blood, and there are numerous angular projections into the cur- 
rents, both which conditions are calculated to induce the spontaneous 
coagulation of the fibrin." We know also that thrombosis generally 
occurs in patients of feeble constitution, often debilitated by hemor- 
rhage, in whom the action of' the heart is much weakened. These 
facts of themselves go far to meet the objections of those who deny 
the possibility of spontaneous coagulation at the roots of the pulmo- 
nary arteries. 

Results of Post-mortem Examinations. — The records of post- 
mortem examinations show also that in many of the cases the right 
side of the heart, as well as the larger branches of the pulmonary 
arteries, contained firm, leathery, decolorized, and laminated coagula, 
which could not have been recently formed. The advocates of the 
purely embolic theory maintain that these are secondary coagula, 
formed round an embolus. But surely the mechanical causes which 
are sufficient to prevent spontaneous deposition of fibrin would also 
suffice to prevent its gathering round an embolus; unless, indeed, the 
obstruction was sufficient to arrest the circulation altogether, when 
death would occur before there was any time for a secondary deposit. 
Before we can admit the possibility of embolism we must have at least 
one factor — that is, thrombosis — in a peripheral vessel, from which an 
embolus can come. In many of the recorded cases nothing of the 
kind was found, and although, as is argued, this may have been over- 
looked, yet such an oversight can hardly always have been made. 

The strongest argument, however, in favor of the spontaneous origin 
of pulmonary thrombosis is one which I originally pointed out in a 
series of papers "On Thrombosis and Embolism of the Pulmonary 
Artery as a Cause of Death in the Puerperal State." 1 I there showed 
from a careful analysis of 25 cases of sudden death after delivery, in 
which accurate post-mortem examinations had been made, that cases 
of spontaneous thrombosis and embolism may be divided from each 
other by a clear line of demarcation, depending on the period after 
delivery at which the fatal result occurs. In 7 out of these cases there 
was distinct evidence of embolism, and in them death occurred at a 
remote period after delivery ; in none before the nineteenth day. This 
contrasts remarkably with the cases in which the post-mortem exami- 
nation afforded no evidence of embolism. These amounted to 15 out 
of the 25, and in all of them, with one exception, death occurred 
before the fourteenth clay, often on the second or third. The reason 
of this seems to be that, in the former, time is required to admit of 
degenerative changes taking place in the deposited fibrin leading to 
separation of an embolus; while in the latter the thrombosis corre- 
sponds in time, and to a great extent no doubt also in cause, to the 
original peripheral thrombosis from which, in the former, the embolus 
was derived. Many cases I have since collected illustrate the same 
rule in a very curious and instructive way. 

Another clinical fact I have observed points to the same conclusion. 
In one or two cases distinct sigus of pulmonary obstruction have 

i Lancet, 1867. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 661 

shown themselves without proving immediately fatal, and shortly 
afterward peripheral thrombosis, as evidenced by phlegmasia dolens 
of one extremity, has commenced. Here the peripheral thrombosis 

obviously followed the central, both being produced by identical 
causes, and the order of events necessary to uphold the purely embolic 
theory was reversed. 

I hold, then, that those who deny the possibility of spontaneous 
coagulation in the heart and pulmonary arteries do so on insufficient 
grounds, and that Ave may consider it to be an occurrence, rare no 
doubt, but still sufficiently often met with, and certainly of sufficient 
importance, to merit very careful study. 

History. — Br. Charles D. Meigs, of Philadelphia, w T as one of the 
first to direct attention to spontaneous coagulation of the blood in the 
right side of the heart and pulmonary arteries as a cause of sudden 
death in the puerperal state. The occurrence itself, however, has been 
carefully studied by Paget, whose paper was published in 1855, four 
years before Meigs wrote on the subject. 1 It is true that none of 
Paget's eases happened after delivery, but he none the less clearly 
apprehended the nature of the obstruction. In 1855, Hecker 2 attrib- 
uted the majority of these cases to embolism proper ; and since that 
date most authors have taken the same view, believing that sponta- 
neous coagulation only occurs in exceptional cases, such as those in 
which, on account of some obstruction in the lung or in the debility 
of the last few r hours before death, coagula form in the smaller rami- 
fications of the pulmonary arteries, and gradually creep back toward 
the heart. 

Symptoms of Pulmonary Obstruction. — The symptoms can 
hardly be mistaken, and there seems to be no essential difference 
between the symptomatology of spontaneous and embolic obstructions, 
so that the same description will suffice for both. In a large propor- 
tion of cases the attack comes on with an appalling suddenness, which 
forms one of its most striking characteristics. Xothing in the con- 
dition of the patient need have given rise to the least suspicion of 
impending mischief, when all at once an intense and horrible dyspnoea 
comes on ; she gasps and struggles for breath ; tears off the coverings 
from her chest in a vain endeavor to get more air ; and often dies in 
a few minutes, long before medical aid can be had, with all the symp- 
toms of asphyxia. The muscles of the face and thorax are violently 
agitated in the attempt to oxygenate the blood, and an appearance 
closely resembling an epileptic convulsion may be presented. The 
face may be either pale or deeply cyanosed. Thus, in one case I have 
elsewhere recorded, which was an undoubted example of true embolism, 
Mr. Pedler, the resident accoucheur at King's College Hospital, who 
was present during the attack, writes of the patient : 3 " She was suffer- 
ing from extreme dyspnoea, the countenance was excessively pale, her 
lips white, the face generally expressing deep anxiety." In another, 

1 MeclicoChirur. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352. Philadelphia Medical Ex- 
aminer, 1849. 

2 Deutsche Klinik, 1855. 

3 Brit. Med. Joum., 1869, vol. i. p. 282. 



662 THE PUERPERAL STATE. 

which was probably an example of spontaneous thrombosis, 1 occurring 
on the twelfth day after delivery, it is stated : " The face had assumed 
a livid purple hue, which was so remarkable as to attract the attention 
both of the nurse and of her mother, who was with her." The extreme 
embarrassment of the circulation is shown by the tumultuous and 
irregular action of the heart in its endeavor to send the venous blood 
through the obstructed pulmonary arteries. Soon it gets exhausted, 
as shown by its feeble and fluttering beat. The pulse is thread-like 
and nearly imperceptible, the respirations short and hurried, but air 
may be heard entering the lungs freely. The intelligence during the 
struggle is unimpaired ; and the dreadful consciousness of impending 
death adds not a little to the patient's sufferings and to the terror of 
the scene. Such is an imperfect account of the symptoms, gathered 
from a record of what has been observed in fatal cases. It will be 
readily understood why, in the presence of so sudden and awful an 
attack, symptoms have not been recorded with the accuracy of ordinary 
clinical observation. 

Is Recovery Possible ? — A question of great practical interest, 
which has been entirely overlooked by writers on the subject, is, Have 
we any ground for supposing that there is a possibility of recovery 
after symptoms of pulmonary obstruction have developed themselves? 
That such a result must be of extreme rarity is beyond question ; but 
I have little doubt that in some few cases, entirely inexplicable on any 
other hypothesis, life is prolonged until the coagulum is absorbed and 
the pulmonary circulation restored. In order to admit of this it is, 
of course, essential that the obstruction be not sufficient to prevent the 
passage of a certain quantity of blood to the lungs to carry on the 
vital functions. The history of many cases tends to show that the 
obstructing clot was present for a considerable time before death, and 
that it was only when some sudden exertion was made, such as rising 
from bed or the like, calling for an increased supply of blood which 
could not pass through the occluded arteries, that the fatal symptoms 
manifested themselves. This was long ago pointed out by Paget, 2 who 
says : " The case proves that, in certain circumstances, a great part of 
the pulmonary circulation may be arrested in the course of a week (or 
a few days, more or less) without immediate danger to life, or any 
indication of what had happened. " And after referring to some 
illustrative cases : " Yet in all these cases the characters of the clots 
by which the pulmonary arteries were obstructed showed plainly that 
they had been a week or more in the process of formation." If we 
admit the possibility of the continuance of life for a certain time, we 
"must, I think, also admit the possibility, in a few rare cases, of eventual 
complete recovery. What is required is time for the absorption of 
the clot. In the peripheral venous system coagula are constantly 
removed by absorption. So strong, indeed, is the tendency to this, 
that Humphry observes with regard to it : " It appears that the blood 
is almost sure to revert to its natural channel in process of time." 3 

1 Obst. Trans., 1871, vol. xii. p. 194. 

2 Op. cit., p. 358. 

8 Med.-Chir. Trans., vol. xxvii. p. 14. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 663 

It', then, the obstruction be only partial, if sufficient blood pass to keep 
the patient alive, and a sudden supply of oxygenated blood is not 
demanded by any exertion which the embarrassed circulation is unable 
to meet, it is not inconceivable that the patient may live until the 
obstruction is removed. 

Illustrative Cases. — Such I believe to be the only explanation of 
certain cases, some of which, on any other hypothesis, it is impossible 
to understand. The symptoms are precisely those of pulmonary 
obstruction, and the description I have given above may be applied 
to them iu every particular ; and after repeated paroxysms, each of 
which seems to threaten immediate dissolution, an eventual recovery 
takes place. What, then, I am entitled to ask, can the condition be, 
if not that which I suggest ? As the question I am considering has 
never, so far as I am aware, been treated of by any other writer, I 
may be permitted to state very briefly the facts of one or two of the 
cases on which I found my argument, some of which I have already 
published in detail elsewhere. 

K. H., delicate young lady. Labor easy. First child. Profuse post-partum hemorrhage. Did 
well until the seventh day. during the whole of which she felt weak. Same day an alarming attack 
of dyspnoea came ou. For several days she remained in a very critical condition, the slightest 
exertion bringing on the attacks. A slight blowing murmur heard for a few days at the base of 
the heart, then it disappeared. For two months patient remained in the same state. As long as 
she was in the recumbent position she felt pretty comfortable ; but any attempt at sitting up in 
bed, or any unusual exertion, immediately brought on the embarrassed respiration. During all 
this time it was found necessary to administer stimulants profusely to ward off the attacks. Event- 
ually the patient recovered completely. 

Q. F., aged forty-four years. Mother of twelve children. Confined on July 6th. On the eleventh 
day she went to bed feeling well. There was no swelling or discomfort of any kind about the 
lower extremities at this time. About 3.30 a.m. she was sitting up in bed, when she was suddenly 
attacked with an indescribable sense of oppression in the chest, and fell back in a semi-unconscious 
state, gasping for breath. She remained in a very critical condition, with the same symptoms of 
embarrassed respiration, for three days, when they gradually passed away. Two days after the 
attack phlegmasia dolens came on, the leg swelled, and remained so for several months. 

This case is an example of the fact I have already referred to, 
of phlegmasia dolens coming on after the symptoms of pulmonary 
obstruction had manifested themselves ; the inference being that both 
depended on similar causes operating on two distinct parts of the 
circulatory system. 1 

C. H., aged twenty-four years. Confined of her first child on August 20, 1867. Thirty hours after 
delivery she complained of great weakness and dyspnoea. This was alleviated by the treatment 
employed, but on the ninth day, after making a sudden exertion, the dyspnoea returned with in- 
creased violence, and continued unabated until I saw the patient on September 4th, fourteen days 
after her confinement. The following are the notes of her condition, made at the time of her 
visit: "I found her sitting on the sofa, propped up with pillows, as she said she could not 
breathe in the recumbent position. The least excitement or talking brought on the most aggra- 
vated dyspnoea, which was so bad as to threaten almost instant death. Her sufferings during these 
paroxys'ms were terrible to witness. She panted and struggled for breath, and her chest heaved 
with short gasping respirations. She could not even bear anyone to stand in front of her, waving 
them away with her hand, and calling for more air. These attacks were very frequent, and were 
Drought on by the most trivial causes. She talked in a low, suppressed voice, as if she could not 
spare breath for articulation. On auscultation air was found to enter the lungs freely in every 
direction, both in front and behind. Immediately over the site of the pulmonary arteries there 
was a distinct harsh, rasping murmur, confined to a very limited space, and not propagated either 
upward or downward. The heart-sounds were feeble and tumultuous." These symptoms led me 
to diagnose pulmonary obstruction, and I of course gave a most unfavorable prognosis, but to 
my great surprise the patient slowly recovered. I saw her again six weeks later, when her heart- 
sounds were regular and distinct and the murmur had completely disappeared. 



i An interesting example of this occurrence has been kindly communicated to me by Dr. Neville, 
of Bristol. The patient, a primipara, aged twenty years, was suddenly seized with well-marked 
svmptoms of pulmonary obstruction on January 24, 1892, three days before delivery. She was con- 
fined on the 27th, her condition from apnoea being then so critical that death was momentarily 
expected. Thirtv hours after delivery symptoms of phlegmasia dolens, with painful swelling of 
both legs and thighs, occurred. After a protracted illness the patient gradually recovered. This 
case is of special interest, since the symptoms of pulmonary obstruction occurred before delivery. 
The onlv other instance of the same kind I know of has been recently recorded by Dr. Church 
(Trans, of the Obstet. Soc. of Edin., vol. xvii. p. 211), and that ended fatally. 



664 THE PUEKPEKAL STATE. 

E. E., aged forty-two years, was confined for the first time on November 5, 1873, in the sixth 
month of utero-gestation. She had severe post-partum hemorrhage, depending on partially ad- 
herent placenta, which was removed artificially. She did perfectly well until the fourteenth day 
after delivery, when she was suddenly attacked with intense dyspncea, aggravated in paroxysms. 
Pulse pretty full, 130, but distinctly intermittent. Air entered lungs freely, The heart's action 
was fluttering and irregular, and at the juncture of the fourth and fifth ribs with the sternum 
there was a loud blowing systolic murmur. This was certainly non-existent before, as the heart 
had been carefully auscultated before administering chloroform during labor. For two days the 
patient remained in the same state, her death being almost momentarily expected. On the 21st — 
that is, two days after the appearance of the chest symptoms — phlegmasia dolens of a severe kind 
developed itself in the right thigh and leg. She continued in the same state for many days, lying 
more or less tranquilly, but having paroxysms of the most intense apnoea, varying from two to 
six or eight in the twenty-four hours. No one who saw her in one of these could have expected 
her to live through it. Shortly after the first appearance of the paroxysms it was observed that 
the cellular tissue of the neck and part of the face became swollen and cedematous, giving an 
appearance not unlike that of phlegmasia dolens, The attacks were always relieved by stimu- 
lants. These she incessantly called for, declaring that she felt that they kept her alive. During 
all this time the mind was clear and collected. The pulse varied from 110 to 130 ; respirations 
about 60 ; temperature 101° to 102.5°. By slow degrees the patient seemed to be rallying. The 
paroxysms diminished in number, and after December 1st she never had another, and the breath- 
ing became tree and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. 
The patient remained, however, very weak and feeble, and the debility seemed to increase. 
Toward the second week in December she became delirious, and died, apparently exhausted, 
without any fresh chest symptoms, on the 19th of that month. No post-mortem examination was 
allowed. 

I have narrated this case, although it terminated fatally, because I 
hold it to be one of the class I am considering. The death was cer- 
tainly not due to the obstruction, all symptoms of which had disap- 
peared, but apparently to exhaustion from the severity of the former 
illness. It illustrates, too, the simultaneous appearance of symptoms 
of pulmonary obstruction and peripheral thrombosis. The swelling 
of the neck was a curious symptom, which has not been recorded in 
any other cases, and may possibly be a further proof of the analogy 
between this condition and phlegmasia dolens. 

Such Cases can only Depend on Pulmonary Obstruction. — 
Now it may, of course, be argued that these cases do not prove my 
thesis, inasmuch as I only assume the presence of a coagulum. But 
I may fairly ask in return, What other condition could possibly explain 
the symptoms? They are precisely those which are noticed in death 
from undoubted pulmonary obstruction. No one seeing one of them, 
or even reading an account of the symptoms, while ignorant of the 
result, could hesitate a single instant in the diagnosis. Surely, then, 
the inference is fair that they depended on the same cause. In the 
very nature of things my hypothesis cannot be verified by post-mortem 
examination ; but there is at least one case on record in which, after 
similar symptoms, a clot was actually found. The case is related by 
Dr. Richardson. 1 It was that of a man who for weeks had symptoms 
precisely similar to those observed in the cases I have narrated. In 
one of his agonizing struggles for breath he died, and after death it 
was found " that a fibrinous band, having its hold in the ventricle, 
extended into the pulmonary artery," This observation proves to a 
certainty that life may continue for weeks after the depositing of 
a coagulum ; and, moreover, this condition was precisely what we 
should anticipate, since, of course, the obstructing coagulum must 
necessarily be small, otherwise the vital functions would be imme- 
diately arrested. 

Cardiac Murmurs in Pulmonary Obstruction. — There is a 
symptom noted in two of the above cases, and to a less extent in a 

1 Clinical Essays, p. 224 et seq. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 665 

third, which has not been mentioned in any account of fatal cases 
occurring after delivery, viz., a murmur over the site of the pulmonary 
arteries. It is a sign we should naturally expect, and very possibly it 
would he met with in fatal cases if attention were particularly directed 
to the point. In both these instances it was exceedingly well marked, 
and in both it entirely disappeared when the symptoms abated. The 
probability of such a murmur being- audible in cases of thrombosis of 
the pulmonary artery has been recognized by one of our highest 
authorities in cardiac disease, who actually observed it in a non- 
puerperal case. In the last edition of his work on diseases of the 
heart, Dr. AValshc 1 says: "The only physical condition connected 
with the vessel itself would probably be systolic basic murmur follow- 
ing the course of the pulmonary main trunk and of its immediate 
divisions to the left and right of the sternum. This sign I most cer- 
tainly heard in an old gentleman whose life w r as brought to a sudden 
close in the course of an acute affection by coagulation in the pulmonary 
artery, and to a moderate extent in the right ventricle. 

Similar cases have, probably, been overlooked or misinterpreted. 
Many seem to have been attributed to shock, in the absence of a better 
explanation, a condition to which they bear no kind of resemblance. 

Causes of Death. — The precise mode of death in pulmonary ob- 
struction, whether dependent on thrombosis or embolism, has given 
rise to considerable difference of opinion. "Virchow attributes it to 
syncope, 2 depending on stoppage of the cardiac contraction. Panum, 3 
on the other hand, contests this view, maintaining that the heart con- 
tinues to beat even after all signs of life have ceased. Certainly 
tumultuous and irregular pulsations of the heart are prominent symp- 
toms in most of the recorded cases, and are not reconcilable with the 
idea of syncope. Pan urn's own theory is that death is the result of 
cerebral anaemia. Paget seems to think that the mode of death is 
altogether peculiar, in some respects resembling syncope, in others 
anaemia. Bertin, who has discussed the subject at great length, 
attributes the fatal result purely to asphyxia. The condition, indeed, is 
in all respects similar to that state, the oxygenation of the blood being 
prevented, not because air cannot get to the blood, but because blood 
cannot get to the air. The symptoms also seem best explained by this 
theory ; the intense dyspnoea, the terrible struggle for air, the preserva- 
tion of intelligence, the tumultuous action of the heart, are certainly 
not characteristic either of syncope or anaemia. 

Post-mortem Appearances of Clots. — The anatomical character 
of the clots seems to vary considerably. Ball, by whom they have 
been most carefully described, believes that they generally commence 
in the smaller ramifications of the arteries, extending backward toward 
the heart, and filling the vessels more or less completely. Toward its 
cardiac extremity the coagulum terminates in a rounded head, in which 
respect it resembles those spontaneously formed in the peripheral 
veins. It is non-adherent to the coats of the vessels, and the blood 
circulates, when it can do so at all, between it and the vascular walls. 

i Walshe : On Diseases of the Heart, 4th ed., 1873. 

2 Gesamm. Abhandl., 1862, p. 316. Virchow's Archiv, 1863 



66Q THE PUEKPERAL STATE. 

Such clots are white, dense, and of a homogeneous structure, consisting 
of layers of decolorized fibrin, firm at the periphery, where the fibrin 
has been most recently deposited, and softened in the centre where 
amylaceous or fatty degeneration has commenced. Ball maintains that 
if the coagulum have commenced in the larger branches of the arteries, 
it must have first begun in the ventricle and extended into them. 
According to Humphry the same changes take place in pulmonary as 
in peripheral thrombi, and they may become adherent to the walls of 
the vessels or converted into threads or bands. When the obstruction 
is due to embolism, provided the case is a well-marked one and the 
embolus of some size, the appearances presented are different. We 
have no longer a laminated and decolorized coagulum, with a rounded 
head, similar to a peripheral thrombus. The obstruction in this case 
generally takes place at the point of bifurcation of the artery, and we 
there meet with a grayish -white mass, contrasting remarkably with 
the more recently deposited fibrin before and behind it. It may be 
that the form of the embolus shows that it has recently been separated 
from a clot elsewhere ; and in many cases it has been possible to fit the 
travelled portion to the extremity of the clot from which it has been 
broken. We may also, perhaps, find that the embolus has undergone 
an amount of retrograde metamorphosis corresponding with that of 
the peripheral thrombus from which we suppose it to have come, but 
differing from that of the more recently deposited fibrin around it. It 
must be admitted, however, that the anatomical peculiarities of the 
coagula will by no means always enable us to trace them to their true 
origin. In many cases emboli may escape detection from their small- 
ness or from the quantity of fibrin surrounding them. 

Treatment. — But few words need be said as to the treatment of 
pulmonary obstruction. In a large majority of cases the fatal result 
so rapidly follows the appearance of the symptoms that no time is 
given us even to make an attempt to alleviate the patient's sufferings. 
Should we meet with a case not immediately fatal, it seems that there 
are but two indications of treatment affording the slightest rational 
ground of hope. 

1. To keep the patient alive by the administration of stimulants — 
brandy, ether, ammonia, and the like — to be repeated at intervals cor- 
responding to the intensity of the paroxysms and the results produced. 
In the cases I have above narrated, in which recovery ensued, this 
took the place of all other medication. Possibly leeches, or dry cup- 
ping to the chest, might prove of some service in relieving the circu- 
lation. 

2. To enjoin the most absolute and complete repose. The object of 
this is evident. The only chance for the patient seems to be that the 
vital functions should be carried on until the coagulum has been 
absorbed, or at least until it has been so much lessened in size as to 
admit of blood passing it to the lungs. The slightest movements may 
give rise to a fatal paroxysm of dyspnoea, from the increased supply of 
oxygenated blood required. It must not be forgotten that in a large 
proportion of cases death immediately followed some exertion in itself 
trivial, such as rising out of bed. Too much attention, then, cannot 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 667 

be given to this point. The patient should be kept absolutely still ; 
she should be fed with abundance of fluid food, such as milk, strong 
soups, and the like ; and she should on no account be permitted to 
raise herself in bed, or attempt the slightest muscular exertion. If we 
are fortunate enough to meet with a case apparently tending to recovery, 
these precautions must be carried on long after the severity of the 
symptoms has lessened, for a moment's imprudence may suffice to 
bring them back in all their original intensity. 

Bertin, 1 indeed, recommends a system of treatment very different 
from this. In the vain hope that the violent effort induced may cause 
the displacement of the impacted embolus (to which alone he attributes 
pulmonary obstruction), he recommends the administration of emetics. 
Few, I fancy, will be found bold enough to attempt so hazardous a 
plan of treatment. 

Various drugs have been suggested in these cases. Richardson 2 
recommended ammonia, a deficiency of which he at that time believed 
to be the chief cause of coagulation. He has since advised that liquor 
amnionise should be given in large doses, twenty minims every hour, 
in the hope of causing solution of the deposited fibrin ; and he has 
stated that he has seen good results from the practice. Others advise 
the administration of alkalies, in the hope that they may favor 
absorption. The best that can be said for them is that they are not 
likely to do much harm. The inhalation of oxygen, which has been 
used with great success in severe pneumonia, 3 is obviously a hopeful 
remedy in this condition, and is well worthy of trial. 

Puerperal Pleuro-pneumonia. — This is, perhaps, the best place to 
mention an important but little understood class of cases which I 
believe to be less uncommon than is generally supposed. I refer to 
severe pleuro-pneumonia occurring in connection with the puerperal 
state, but not distinctly associated with septicaemia. Two carefully 
observed cases of this kind are recorded by MacDonald, occurring in 
his practice ; I myself have met with three very marked examples 
within the past three years, one of which proved fatal, the other two 
giving rise to most serious illness, from which the patient recovered 
with difficulty. 

So far as my own observation goes there are marked peculiarities in 
such cases which clearly differentiate them from the ordinary course of 
pneumonia. The onset is sudden and unconnected with exposure to 
cold or other cause of lung disease ; there is no definite crisis, but a 
continuous pyrexia of moderate intensity lasting a variable time ; and 
the physical signs differ from those of ordinary pneumonia. 

Physical Signs. — In MacDonald's case, as well as in my own, they 
were peculiar in this respect, that there was very slight crepitation, 
marked rusty sputum, and a wooden dulness, much more intense than 
in ordinary pneumonia, extending over a large lung space, with a very 
slight entrance of air into the lung tissue. It is also remarkable that 
a very large proportion of the cases were associated with phlegmasia 

1 Op. cit., p. 393. 

2 Heart Disease during Pregnancy, p. 209. 

s "On the Use of Oxygen and Strychnia in Pneumonia," Brit. Med. Journ., January 23, 1892. 



668 THE PUERPERAL STATE. 

dolens. Thus it existed in one of MacDonald's two cases, and in two 
out of my own three. Like phlegmasia dolens, moreover, the disease 
generally commenced some weeks after delivery ; my own cases, for 
example, occurred respectively fifteen, twenty-eight, and thirty-five 
days after labor. It is difficult to believe that there is not some 
connection between these two conditions, and there is much in their 
peculiar history to lead to the belief that such forms of lung disease 
depend, in fact, on the thrombotic or embolic obstruction of the minute 
branches of the pulmonary arteries, caused by conditions similar to 
those which have produced the phlebitic obstructions in the lower 
extremities. In the absence of careful post-mortem examination this 
hypothesis is clearly not susceptible of proof. MacDonald, while 
admitting that " a limited thrombosis of the pulmonary arteries would 
no doubt explain the facts of the cases," is rather inclined to " seek 
the chief explanation of their occurrence in the alterations which the 
pregnant and puerperal conditions impress upon the blood and the 
blood-vascular system." 

I confess that to my mind the former hypothesis is not only the 
most definite, but the one which most readily explains all the pecu- 
liarities of these cases. I cannot, however, do more thau suggest it, 
in the hope that further observations, and especially carefully con- 
ducted autopsies, may throw some light on this obscure and little- 
studied subject. 

Treatment. — As regards treatment, it is obvious that it must be 
conducted on general principles, carefully avoiding over-severe meas- 
ures, and supporting the patient through a trial to the system that 
must necessarily be severe. 



CHAPTEE VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

Arterial Thrombosis and Embolism. — The same condition of the 
blood which so strongly predisposes to coagulation in the vessels 
through which venous blood circulates tends to similar results in the 
arterial system. These, however, are by no means so common, and 
do not, as a rule, lead to such important consequences. The subject 
has been but little studied, and almost all our knowledge of it is 
derived from a very interesting essay by Sir James Simpson. 1 As I 
have devoted so much space to the consideration of venous thrombosis 
and embolism, I shall but briefly consider the effects of arterial ob- 
struction. 

Causes. — In a considerable number of recorded cases the obstruc- 

i Selected Obstet. Works, vol. i. p. 523. 



PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 669 

tion lias resulted from the detachment of vegetations deposited on the 
cardiac valves, the result of endocarditis, either produced by antecedent 
rheumatism or as a complication of the puerperal state. Sometimes 
the obstruction seems to depend on some general blood dyscrasia, 
similar to that producing venous thrombosis, or on some local change 
in the artery itself. Thus Simpson records a case apparently produced 
by local arteritis, which caused acute gangrene of both lower extremi- 
ties, ending fatally in the third week after delivery. In other cases it 
has been attributed to coagulation following spontaneous laceration 
and corrugation of the internal coat of the artery. 

Symptoms. — The symptoms of puerperal arterial obstruction must, 
of course, vary with the particular arteries affected. Those with the 
obstruction of which we are most familiar are the cerebral, the brachial, 
and the femoral. The effects produced must also be modified by the 
size of the embolus, and the more or less complete obstruction it pro- 
duces. Thus, for example, if the middle cerebral artery be blocked 
up entirely, the functions of those portions of the brain supplied by it 
will be more or less completely arrested, and hemiplegia of the oppo- 
site side of the body, followed by softening of the brain texture, will 
probably result. If the nervous symptoms be developed gradually, 
or increase in intensity after their first appearance, it may be that an 
obstruction, at first incomplete, has increased by the deposition of 
fibrin around it. So the occasional sudden supervention of blindness, 
with destruction of the eyeball — cases of which are recorded by 
Simpson — not improbably depend on the occlusion of the ophthalmic 
artery, the function of the organ depending on its supply through the 
single artery. The effects of obstruction of the visceral arteries in 
the puerperal state are entirely unknown, but it is far from unlikely 
that further investigation may prove them to be of great importance. 
In the extremities arterial obstruction produces effects which are well 
marked. They are classified by Simpson under the following heads : 
1. Arrest of puke below the site of obstruction. This has been observed 
to come on either suddenly or gradually, and, if the occlusion be in 
one of the large arterial trunks, it is a symptom which a careful ex- 
amination will readily enable us to detect. 2. Increased force of 
pulsation in the arteries above the seat of obstruction. 3. Fall in the 
temperature of the limb. This is a symptom which is easily api^reciable 
by the thermometer, and Avhen the main artery of the limb is occluded 
the coldness of the extremity is well marked. 4. Lesions of motor 
and sensory functions, 'paralysis, neuralgia, etc. Loss of power in 
the affected limb is often a prominent symptom, and when it comes 
on suddenly, and is complete, the main artery will probably be 
occluded. It may be diagnosed from paralysis depending on cerebral 
or spinal causes by the absence of head symptoms, by the history of 
the attack, and by the presence of other indications of arterial obstruc- 
tion, such as loss of pulsation in the artery, fall of temperature, etc. 
The sensory functions in these cases are generally also seriously dis- 
turbed, not so much by loss of sensation as by severe pain and neur- 
algia. Sometimes the pain has been excessive, and occasionally it has 
been, the first symptom which directed attention to the state of the 



670 THE PUEKPERAL STATE. 

limb. 5. Gangrene below or beyond the seat of arterial obstruction. 
Several interesting cases are recorded in which gangrene has followed 
arterial obstruction. Generally speaking, gangrene will not follow 
occlusion of the main arterial trunk of an extremity, as the collateral 
circulation soon becomes sufficiently developed to maintain its vitality. 
In many of the cases either thrombi have obstructed the channels of 
collateral circulation as well, or the veins of the limb have also been 
blocked up. When such extensive obstructions occur, they obviously 
cannot be embolic, but must depend on a local thrombosis, traceable 
to some general blood dyscrasia depending on the puerperal state. 

Treatment. — Little can be said as to the treatment of such cases, 
which must vary with the gravity and nature of the symptoms in 
each. Beyond absolute rest (in the hope of eventual absorption of the 
thrombus or embolus), generous diet, attention to the general health 
of the patient, and sedative applications to relieve the local pain, there 
is little in our power. Should gangrene of an extremity supervene in 
a puerperal patient, the case must necessarily be well-nigh hopeless. 
Simpson, however, records one instance in which amputation was per- 
formed above the line of demarcation, the patient eventually recovering. 



CHAPTEE VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND 
THE PUERPERAL STATE. 

A large number of the cases in which sudden death occurs during 
or after delivery find their explanation, as I have already pointed out, 
in thrombosis or embolism of the heart and pulmonary arteries. 
Probably many cases of the so-called idiopathic asphyxia were, in fact, 
examples of this accident, the true nature of which had been mis- 
understood. Besides these, there are, no doubt, many other condi- 
tions which may lead to a suddenly fatal result in connection with 
parturition. 

Some of these are of an organic, others of a functional nature. 

Organic Causes. — Among the former may be mentioned cases in 
which the straining efforts of the second stage of labor have produced 
death in patients suffering from some pre-existent disease of the heart. 
Rupture of that organ has probably occurred from fatty degeneration 
of its walls. Dehous 1 narrates an instance in which the efforts of 
labor caused the rupture of an aneurism. Another case, from inter- 
ference with the action of the heart in a patient who had pericardial 
effusion, is narrated by Ramsbotham. Dr. Devilliers relates an 

1 Dehous : Sur les Morts subites. 



CAUSES OF SUDDEN DEATH DURING LABOR. 671 

instance occurring in a young woman during the second stage of 
labor. The heart was found to be healthy , hut the lungs were in- 
tensely congested and blood was extensively extravasated all through 
their texture. This was probably caused by pulmonary congestion 
and apoplexy, produced by the severe straining efforts. Many cases 
from effusion of blood into the brain substance, or on its surface, are 
on record — no doubt in patients who, from arterial degeneration or 
other causes, were predisposed to apoplectic effusions. The so-called 
apoplectic convulsions, formerly described in most works on obstetrics 
as a variety of puerperal convulsions, are evidently nothing more than 
apoplexy coming on during or after labor. As regards their path- 
ology, they do not seem to differ from ordinary cases of apoplexy in 
the non-pregnant condition. One example is recorded of death which 
was attributed to rupture of the diaphragm from excessive action in 
the second stage. 

Functional Causes. — Among the causes of death which cannot be 
traced to some distinct organic lesion may be classed cases of syncope, 
shock, and exhaustion. Many instances of this kind are recorded. 
Thus in some women of susceptible nervous organization the severity of 
the suffering appears to bring on a condition similar to that prodnced 
by excessive shock or exhaustion, which has not unfrequently proved 
fatal. Several examples of this kind have been cited by McClintock. 1 
It is also not unlikely that sudden syncope sometimes produces a fatal 
result during or after labor. Most cases of death otherwise inex- 
plicable used to be referred to this cause ; but accurate autopsies 
were seldom made, and even when they were — the important effects of 
pulmonary coagula being unknown — it is more than probable that the 
true cause of death was overlooked. It has been supposed that the 
sudden removal of pressure from the veins of the abdomen, by the 
emptying of the gravid uterus after delivery, may favor an increased 
afflux of blood into the lower parts of the body, and thus tend to an 
anemic condition of the brain and the production of syncope. How- 
ever this may be, the possibility of its occurrence, and its manifest 
danger in a recently delivered woman, are sufficient reasons for en- 
forcing the recumbent position after labor is over. In some of the 
cases the syncope was evidently produced by the patient suddenly 
sitting upright. 

Death from Air in the Veins. — Some cases of sudden death imme- 
diately after labor seem to be due to the entrance of air into the veins. 
Six examples are cited by McClintock which were probably due to 
this cause. La Chapelle related two. An interesting case is related 
by M. Lionet. 2 In this the patient died five and a half hours after 
an easy and natural labor, the chief symptoms being extreme pallor, 
efforts at vomiting, and dyspnoea. Air was found in the heart and in 
the arachnoid veins. There can be no question that the uterine 
sinuses after delivery are nearly as well adapted as the veins of the 
neck for allowing the entrance of air. They are firmly attached to 
the muscular walls of the uterus, so that they gape open when that 

i Union Med., 1853. 2 Dehous : op. cit., p. 58. 



672 THE PUERPERAL STATE. 

organ is relaxed, and it is easy to understand how air might enter. 
Indeed, in the post-mortem examination in one of the cases occurring 
in the practice of Mme. La Chapelle, it is stated that " the uterine 
sinuses opened in the interior of the uterus by large orifices (one line 
and a half in diameter), through which air could readily be blown as 
far as the iliac veins, and vice versa" The condition of the uterus 
after delivery also enables the air to have ready access to the mouths 
of the sinuses, for the alternate relaxation and contraction of the uterus, 
occurring after the placenta is expelled, would tend to draw in the air 
as by a suction-pump. Hence an additional reason for insisting on 
firm contraction of the uterus, as this will lessen the risk of this 
accident. 

The precise mechanism of death from air in the veins has been a 
subject of dispute among pathologists. By Bichat 1 it was referred to 
ansemia and syncope for want of blood in the vessels of the brain, 
which are occupied by air. Xysten 2 attributed it to distention of the 
cavities of the heart by rarefied air, producing paralysis of its wall ; 
Leroy, to a stoj>page of the pulmonary circulation and cou sequent 
want of proper blood-supply to the left heart ; while Leroy d'Etoilles 
thought it might depend on any of these causes or a combination of 
all of them. These, and many other hypotheses on the subject, have 
been advanced, to all of which serious objection could be raised. The 
most recent theory is one maintained by Virchow and Oppolzer, 3 and 
more recently by Feltz, which attributes the fatal results to impaction 
of the air-globules in the lesser divisions of the pulmonary arteries, 
where they form gaseous emboli, and cause death exactly in the same 
way as when the obstruction depends on a fibrinous embolus. The 
symptoms observed in fatal cases closely correspond to those of pul- 
monary obstruction, and it is not unlikely that some cases attributed 
to other causes, may really depend on the entrance of air through the 
uterine sinuses. Such, for example, was most probably the explana- 
tion of a case referred to by Dr. Graily Hewitt in a discussion at the 
Obstetrical Society. 4 Death occurred shortly after the removal of an 
adherent placenta, during which, no doubt, air could readily enter the 
uterine cavity. The symptoms, viz., " severe pain in the cardiac 
region, distress as regards respiration, and pulselessness," are identical 
with those of pulmonary obstruction. Dr. Hewitt refers the death to 
shock, which certainly does not generally produce such phenomena. 

1 Recherches sur la Vie et la Mort, 1853. 

2 Recherches de Phys. et Chim. Path., 1811. 

3 Kasuistik der Embolien ; Wiener med. Wochenschr., 1862 ; Des Embolies capillaires, 1868 ; and 
op. cit., p. 115. 

« Obst. Trans., 1869, vol. x. p. 28. 



PERIPHERAL VENOUS THROMBOSIS. 673 



CHAPTEE IX. 

PERIPHERAL VENOUS THROMBOSIS— (Syn. : CRURAL PHLEBITIS 

—PHLEGMASIA DOLENS— ANASARCA SEROSA— (EDEMA 

LACTEUM— WHITE LEG, Etc.). 

Peripheral Thrombosis. — "We now come to discuss the symptoms 
and pathology of the conditions associated with the formation of 
thrombi in the peripheral venous system, or rather in the veins of the 
lower extremities, since too little is known of their occurrence in other 
parts to enable ns to say anything on the subject. 

The most important of these is the well-known disease which, under 
the name of phlegmasia dolens, has attracted much attention and given 
rise to numerous theories as to its nature and pathology. In describing 
it as a local manifestation of a general blood dyscrasia, and not as an 
essential local disease, I am making an assumption as to its pathology 
that many eminent authorities would not consider justifiable. I have, 
however, already stated some of the reasons for so doing, aud I hope 
to show shortly that this view is not incompatible with the most 
probable explanation of the peculiar state of the affected limb. 

Symptoms. — The first symptom which usually attracts attention is 
severe pain in some part of the limb that is about to be affected. The 
character of the pain varies in different cases. In some it is extremely 
acute, and is most felt in the neighborhood of, and along the course of, 
the chief venous trunks. It may begin in the groin or hip and extend 
downward; or it may commence in the calf and proceed upward toward 
the pelvis. The pain abates somewhat after swelling of the limb 
(which generally begins within twenty-four hours), but it is always a 
distressing symptom, and continues as long as the acute stage of the 
disease lasts. The restlessness, want of sleep, and suffering which it 
produces are sometimes excessive. Coincident with the pain, and 
sometimes preceding it, more or less malaise is experienced. The 
patient may for a day or two be restless, irritable, and out of sorts, 
without any very definite cause ; or the disease may be ushered in by 
a distinct rigor. Generally there is constitutional disturbance, varying 
with the intensity of the case. The pulse is rapid and weak, 120 or 
thereabouts; the temperature elevated from 101° to 102°, with an 
evening exacerbation. The patient is thirsty ; the tongue is glazed or 
white and loaded ; the bowels constipated. In some few cases, when 
the local affection is slight, none of these constitutional symptoms are 
observed. 

Condition ot the Affected Limb. — The characteristic swelling 
rapidlv follows the commencement of the symptoms. It generally 
begins in the groin, whence it extends downward. It may be limited 

43 



674 THE PUERPERAL STATE. 

to the thigh ; or the whole limb, even to the feet, may be implicated. 
More rarely it commences in the calf of the leg, extending upward to 
the thigh and downward to the feet. The affected parts have a peculiar 
appearance which is pathognomonic of the disease. They are hard, 
tense, and brawny ; of a shiny white color ; and not yielding on press- 
ure, except toward the beginning and end of the illness. The appear- 
ances presented are quite different from those of ordinary oedema. 
When the whole thigh is affected the limb is enormously increased 
in size. Frequently the venous trunks, especially the femoral and 
popliteal veins, are felt obstructed with coagula, and rolling under the 
finger. They are painful w r hen handled, and in their course more or 
less redness is occasionally observed. Either leg may be attacked, but 
the left more frequently than the right. There is a marked tendency 
for the disease to spread, and Ave often find, in a case which is progress- 
ing apparently well, a rise of temperature and an accession of febrile 
symptoms followed by the swelling of the other limb. 

Progress of the Disease. — After the acute stage has lasted from a 
week to a fortnight the constitutional disturbance becomes less marked, 
the pulse and temperature fall, the pain abates, and the sleeplessness 
and restlessness are less. The swelling and tension of the limb now 
begin to diminish and absorption commences. This is invariably a 
slow process. It is always many weeks before the effusion has disap- 
peared, and it may be many months. The limb retains for a length of 
time the peculiar wooden feeling, as Dr. Churchill terms it. Any im- 
prudence, such as a too early attempt at walking, may bring on a 
relapse and fresh swelling of the limb. This gradual recovery is by 
far the most common termination of the disease. In some rare cases 
suppuration may take place either in the subcutaneous cellular tissue, 
the lymphatic glands, or even in the joints, and death may result from 
exhaustion. The possibility of pulmonary obstruction and sudden 
death from separation of an embolus have already been pointed out, 
and the fact that this lamentable occurrence has generally followed 
some undue exertion should be borne in mind as a guide in the man- 
agement of our patient. 

Period of Commencement. — The disease usually begins within a 
short time after delivery, rarely before the second week. In 22 
cases tabulated by Dr. Kobert Lee, 7 were attacked between the 
fourth and twelfth days, and 14 after the second week. Some cases 
have been described as commencing even months after delivery. It is 
questionable if these can be classed as puerperal, for it must not be 
forgotten that phlegmasia dolens is by no means necessarily a puerperal 
disease. There are many other conditions which may give rise to it, all 
of them, however, such as produce a septic and hyperinosed state of the 
blood, such as malignant disease, dysentery, phthisis, and the like. My 
own experience would lead me to think that cases of this kind are 
much more common than is generally believed. 

History and Pathology. — The disease has long attracted the atten- 
tion of the profession. Passing over more or less obscure notices by 
Hippocrates, De Castro, and others, we find the first clear account in 
the writings of Mauriceau, who not only gave a very accurate de- 



PERIPHERAL VENOUS THROMBOSIS. 675 

seription of its symptoms, but made a guess at its pathology, which 
was certainly more happy than the speculations of his successors ; it 
is, he says, caused " by a reflux on the parts of certain humors which 
ought to have been evacuated by the lochia." Puzos ascribed it to the 
arrest of the secretion of milk, and its extravasation in the affected 
limb. This theory, adopted by Levret and many subsequent writers, 
took a strong hold on both professional and public opinions, and to it 
we owe many of the names by which the disease is known to this day, 
such as oedema lacteum, milk leg, etc. In 1784 Mr. White, of Man- 
chester, attributed it to some morbid condition of the lymphatic glands 
and vessels of the affected parts ; and this or some analogous theory, 
such as that of rupture of the lymphatics crossing the pelvic brim, as 
maintained by Tyre, of Gloucester, or general inflammation of the 
absorbents, as held by Dr. Ferrier, was generally adopted. 

It was not until the year 1823 that attention was drawn to the con- 
dition of the veins. To Bouillaud belongs the undoubted merit of 
first pointing out that the veins of the affected limb were blocked up 
by coagula, although the fact had been previously observed by Dr. 
Davis, of University College. Dr. Davis made dissections of the veins 
in a fatal case, and found, as Bouillaud had done, that they were filled 
with coagula, which he assumed to be the results of inflammation of 
their coats; hence the name of crural phlebitis, which has been exten- 
sively adopted, instead of phlegmasia dolens. Dr. Eobert Lee did 
much to favor this view ; and finding that thrombi were present in the 
iliac and uterine, as well as in the femoral, veins, he concluded that 
the phlebitis commenced in the uterine branches of the hypogastric 
veins and extended downward to the femorals. He pointed out that 
phlegmasia dolens was not limited to the puerperal state ; but that 
when it did occur independently of it, other causes of uterine phlebitis 
were present, such as cancer of the os and cervix uteri. The inflam- 
matory theory was pretty generally received, and even now is con- 
sidered by many to be a sufficient explanation of the disease. Indeed, 
the fact that more or less thrombosis was always present could not be 
denied ; and on the supposition that thrombosis could only be caused 
by phlebitis, as was long supposed to be the case, the inflammatory 
theory was the natural one. Before long, how r ever, pathologists pointed 
out that thrombosis was by no means necessarily or even generally the 
result of inflammation of the vessels in which the clot was contained, 
but that the inflammation was more generally the result of the 
coagulum. 

The late Dr. Mackenzie took a prominent part in opposing the 
phlebitic theory. He proved by numerous experiments on the lower 
animals that inflammation is not sufficient of itself to produce the ex- 
tensive thrombi which are found to exist, and that inflammation 
originating in one part of a vein is not apt to spread along its canal, 
as the phlebitic theory assumes. His conclusion is that the origin of 
the disease is rather to be sought in some septic or altered condition of 
the blood, producing coagulation in the veins. Dr. Tyler Smith 1 

1 Tyler Smith : Manual of Obstetrics, p. 538. 



676 THE PUERPERAL STATE. 

pointed out an occasional analogy between the causes of phlegmasia 
dolens and puerperal fever, evidently recognizing the dependence of 
the former on blood dyscrasia. " I believe/' he says, " that contagion 
and infection play a very important part in the production of the 
disease. I look on a woman attacked with phlegmasia dolens as 
having made a fortunate escape from the greater dangers of diffuse 
phlebitis or puerperal fever." In illustration of this he narrates the 
following instructive history: "A short time ago a friend of mine had 
been in close attendance on a patient dying of erysipelatous sore-throat 
with sloughing, and was himself affected with sore-throat. Under 
these circumstances he attended, within the space of twenty-four hours, 
three ladies in their confinements, all of whom were attacked with 
phlegmasia dolens." 

The latest important contribution to the pathology of the disease is 
contained in two papers by Dr. Tilbury Fox, published in the second 
volume of the Obstetrical Transactions. He maintained that some- 
thing beyond the mere presence of coagula in the veins is required to 
produce the phenomena of the disease, although he admitted that to be 
an important and even an essential part of the pathological changes 
present. The thrombi he believed to be produced either by extrinsic 
or intrinsic causes : the former comprising all cases of pressure by 
tumor or the like ; the latter, and the most important, being divisible 
into the heads of — 

1. True inflammatory changes in the vessels, as seen in the epidemic 
form of the disease. 

2. Simple thrombus produced by rapid absorption of morbid fluid. 

3. Virus action and thrombus conjoined, the phlegmasia dolens 
itself being the result of simple thrombus, and not produced by dis- 
eased (inflamed) coats of vessels ; the general symptoms the result of 
the general blood state. 

He further pointed out that the peculiar swelling of the limbs cannot 
be explained by the mere presence of oedema, from which it is essen- 
tially different ; the white appearance of the skin, the severe neuralgic 
pain, and the persistent numbness indicating that the whole of the 
cutaneous textures, the cutis vera, and even the epithelial layer, are 
infiltrated with fibrinous deposit. He concluded, therefore, that the 
swelling is the result of oedema phis something else — that something 
being obstruction of the lymphatics, by which the absorption of 
effused serum is prevented. The efficient cause Avhich produces these 
changes he believes to be, in the majority of cases, a septic action 
originating in the uterus, producing a condition similar to that in 
which phlegmasia dolens arises in the non-puerperal state. 

[Although crural phlebitis is a rare sequel of the Cesarean section, 
it has followed it and the Porro operation, both in this city and ISew 
York, in two cases of each, three of which were seen by the writer. 
It is most likely to occur in amende subjects or where there has been 
a secondary destruction of tissue from injurious pressure in a long 
labor. In my experience it is most likely to show itself about the 
middle of the third week. The disease may occur in delicate men and 
in unmarried women. — Ed.] 



PERIPHERAL VENOUS THROMBOSIS. 677 

There is do doubt much force in Dr. Fox's arguments, and it may, 

I think, be conceded that obstruction of the veins per si is not sufficient 
to produce the peculiar appearance of the limb. It is, moreover, cer- 
tain that phlebitis alone i- also an insufficient explanation not only of 
the symptoms but even of the presence of thrombi so extensive as those 

that are found. The view which trace- the disease solely to inflam- 
mation or obstruction of lymphatics is purely theoretical, has no ba>is 
of tacts to support it, and finds nowadays no supporters. The experi- 
ments of Mackenzie and Lee, as well as the vastly increased knowledge 
of the causes of thrombosis which the researches of modern pathologists 
have given us, seem to point strongly to the view already stated, that 
the disease can only be explained by a general blood dyscrasia de- 
pending on the puerperal state. It by no means follows that we are 
to consider Dr. Fox's speculations as incorrect. It is far from im- 
probable that the lymphatic vessels are implicated in the production 
of the peculiar swelling, only we are not as yet in a position to prove 
it. There is no inherent improbability in the supposition that the 
same morbid state of the blood which produces thrombosis in the veins 
may also give rise to such an amount of irritation in the lymphatics 
as may interfere with their functions and even obstruct them alto- 
gether. The essential and all-important point in the pathology of the 
disease, however, seems undoubtedly to be thrombosis in the veins ; 
and the probability of there being some as yet undetermined patho- 
logical changes in addition to this, by no means militates against the 
view I have taken of the intimate connection of the disease with other 
results of thrombosis in different vessels. 

Changes occurring" in the Thrombi. — The changes which take 
place in the thrombi all tend to their ultimate absorption. These 
have been described by various authors as leading to organization or 
suppuration. It is probable, however, that the appearances which 
have led to such a supposition are fallacious, and that they are really 
due to retrograde metamorphosis of the fibrin, generally of an amy- 
laceous or fatty character. 

Detachment of Emboli. — The peculiarities of a clot that must 
favor detachment of an embolus are such a shape as admits of a portion 
floating freely in the blood current by the force of which it is detached 
and carried to its ultimate destination. When the accident has occurred 
it is often possible to recognize the peripheral thrombus from which 
the embolus has separated, by the fact of its terminal extremity pre- 
senting a freshly fractured end, instead of the rounded head natural to 
it. Such detachment is unlikely to occur, even when favored by the 
shape of the clot, unless sufficient time has elapsed after its formation 
to admit of its softening and becoming brittle. The curious fact I 
have before mentioned, of true puerperal embolism occurring in the 
large majority of cases only after the nineteenth day from delivery, 
finds a ready explanation in this theory, which it remarkably cor- 
roborates. 

Treatment. — On the supposition that phlegmasia dolens was the 
result of inflammation of the veins of the affected limb, an antiphlo- 
gistic course of treatment was naturally adopted. Accordingly, most 



678 THE PUERPERAL STATE. 

writers on the subject recommended depletion, generally by the appli- 
cation of leeches along the course of the affected vessels. We are told 
that if the pain continues, the leeches should be aj3plied a second or 
even a third time. If we admit the septic origin of the disease, we 
must, I think, see the impropriety of such a practice. The fact that 
it occurs in a large majority of cases in patients of a weakly and 
debilitated constitution, often in women who have suffered from hemor- 
rhage, is a further reason for not adopting this routine custom. If 
local loss of blood be used at all, it should be strictly limited to cases 
in which there is much tenderness and redness across the course of the 
veins, and then only in patients of plethoric habits and strong consti- 
tution. Cases of this kind will form a very small minority of those 
coming under oui observation. 

What has been said of the pathology of the affection tends to the 
conclusion that active treatment of any kind, in the hope of curing 
the disease, is likely to be useless. Our chief reliance must be on 
time and perfect rest, in order to admit of the thrombi and the 
secondary effusion being absorbed, while we relieve the pain and other 
prominent symptoms and support the strength and improve the 
constitution of the patient. 

The constant application of heat and moisture to the affected limb 
will do much to lessen the tension and pain. Wrapping the entire 
limb in linseed-meal poultices, frequently changed, is one of the best 
means of meeting this indication. If, as is sometimes the case, the 
weight of the poultice be too great to be readily borne, we may sub- 
stitute warm flannel stupes covered with oiled silk. Local anodyne 
applications afford much relief, and may be advantageously used along 
with the poultices and stupes either by sprinkling their surface freely 
with laudanum or chloroform and belladonna liniment or by soaking 
the flannels in poppy-head fomentations. It is needless to say that 
the most absolute rest in bed should be enjoined, even in slight cases, 
and that the limb should be effectually guarded from undue pressure, 
by a cradle or some similar contrivance. Local counter-irritation has 
been strongly recommended, and frequent blisters have been considered 
by some to be almost specific. I should myself hesitate to use blisters, 
as they would certainly not be soothing applications, and one hardly 
sees how they can be of much service in hastening the absorption of 
the effusion. 

During the acute stage of the disease the constitutional treatment must 
be regulated by the condition of the patient. Light but nutrious diet 
must be administered in abundance, such as milk, beef-tea, and soups. 
Should there be much debility, stimulants in moderation may prove of 
service. With regard to medicines, we shall probably find benefit from 
such as are calculated to improve the condition of the blood and the 
general health of the patient. Chlorate of potash with diluted hydro- 
chloric acid, quinine either alone or in combination with sesquicar- 
bonate of ammonia, the tincture of the perchloride of iron, are the 
drugs that are most likely to prove of service. Alkalies and other 
medicines, which have been recommended in the hope of hastening the 
absorption of coagula, must be considered as altogether useless. Pain 



PERIPHERAL VENOUS THROMBOSIS. 679 

must be relieved and sleep procured by the judicious use of anodynes, 
such as Dover's powder, the subcutaneous injection of morphia, or 
chloral. Generally no form answers so well as the hypodermic in- 
jection of morphia. 

When the acute symptoms have abated and the temperature has 
fallen, the poultices and stupes may be discontinued and the limbs 
swathed in a flannel roller from the toes upward. The equable pres- 
sure and support thus afforded materially aid the absorption of the 
effusion and tend to diminish the size of the limb. At a still later 
stage very gentle inunctions of weak iodine ointment may be used 
with advantage once a day before the roller is applied. Shampooing 
and friction of the limb, generally recommended for the purpose of 
hastening absorption, should be carefully avoided, on account of the 
possible risk of detaching a portion of the coagulum and producing 
embolism. This is no merely imaginary danger, as the following fact 
narrated by Trousseau proves : " A phlegmasia alba dolens had ap- 
peared on the left side in a young woman suffering from peri-uterine 
phlegmon. The pain having ceased, a thickened venous trunk was 
felt on the upper and internal part of the thigh. Rather strong 
pressure was being made, when M. Demarquay felt something yield 
under his fingers. A few minutes afterward the patient was attacked 
with dreadful palpitation, tumultuous cardiac action, and extreme 
pallor, and death was believed to be imminent. After some hours, 
however, the oppression ceased and the patient eventually recovered. 
A slightly attached coagulum must have become separated and con- 
veyed to the heart or pulmonary artery." * Warm douches of water — 
of salt water, if it can be obtained — may be advantageously used in 
the later stages of the disease, and they may be applied night and 
morning, the limb being bandaged in the interval. The occasional 
use of the continuous current is said to promote absorption, and would 
seem likely to be a serviceable remedy. 

When the patient is well enough to be moved, a change of air to 
the seaside will be of value. Great caution, how r ever, should be 
recommended in using the limb, and it is far better not to run the 
risk of a relapse by any undue haste in this respect. It is well to warn 
the patient and her friends that a considerable time must of necessity 
elapse before the local signs of the disease have completely disappeared. 

1 Trousseau : Clinique de l'Hotel-Dieu, in Gaz. des Hop., 1860, p. 577. 



680 THE PUERPERAL STATE. 



CHAPTEE X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Recognized from the Earliest Times. — From the earliest times 
the occurrence after parturition of severe forms of inflammatory 
disease in and about the pelvis, frequently ending in suppuration, 
has been well known. It is only of late years, however, that these 
diseases have been made the subject of accurate clinical and patho- 
logical investigation, and that their true nature has begun to be 
understood. Nor is our knowledge of them as yet by any means 
complete. They merit careful study on the part of the accoucheur, 
for they give rise to some of the most severe and protracted illnesses 
from which puerperal patients suffer. They are often obscure in their 
origin and apt to be overlooked, and they not rarely leave behind 
them lasting mischief. 

These diseases are not limited to the puerperal state. On the con- 
trary, many of the severest cases arise from causes altogether un- 
connected with childbearing. These will not be now considered, and 
this chapter deals solely with such forms as may be directly traced to 
childbirth. 

Modern researches have demonstrated that there are two distinct 
varieties of inflammatory disease met with after labor which differ 
materially from each other in many respects. In one of these the 
inflammation affects chiefly the connective tissue surrounding the 
generative organs contained within the pelvis, or extends up from 
beneath the peritoneum and into the iliac fossae. In the other it 
attacks that portion of the peritoneum which covers the pelvic viscera, 
and is limited to it. 

Variety of Nomenclature. — So much is admitted by all writers; 
but great obscurity in description, and consequent difficulty in under- 
standing satisfactorily the nature of these affections, have resulted 
from the variety of nomenclature which different authors have adopted. 

Thus the former disease has been variously described as pelvic cellu- 
litis, peri-uterine phlegmon, para-metritis, or pelvic abscess ; while the 
latter is not unfrequently called peri-metritis, as contradistinguished 
from para-metritis. The use of the prefix para or peri, to distinguish 
the cellular or peritoneal variety of inflammation, originally suggested 
by Yirchow, has been pretty generally adopted in Germany, and has 
been strongly advocated in Great Britain by Matthews Duncan. It has 
never, however, found much favor with English writers, and the simi- 
larity of the two names is so great as to lead to confusion. I have, 
therefore, selected the terms pelvic peritonitis and pelvic cellulitis, as con- 
veying in themselves a fairly accurate notion of the tissues mainly 
involved. 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 681 

Importance of Distinguishing* the Two Classes of Cases. — 
The important fact to remember is that there exist two distinct varieties 
of inflammatory disease presenting many similarities in their course, 
symptoms, and results, often occurring simultaneously, but in the main 
distinct in their pathology and capable of being differentiated. Thomas 
compares them — and, as serving to fix the tacts on the memory, the 
illustration is a good one — to pleurisy and pneumonia. " Like them/ 9 
he says, 4i they are separate and distinet, like them affect different kinds 
of structure, and like them they generally complicate each other." It 
might, therefore, be advisable, as most writers on the disease occurring 
in the non-puerperal state have done, to treat of them in two separate 
chapters. There is, however, more difficulty in distinguishing them as 
puerperal than as non-puerperal affections, for which reason, as well as 
for the sake of brevity, I think it better to consider them together, 
pointing out as I proceed the distinctive peculiarities of each. 

Seat of Disease. — "When attention was first directed to this class of 
diseases the pelvic cellular tissue was believed to be the only structure 
affected. This was the view maintained by Xonat, Simpson, and many 
modern writers. Attention was first prominently directed to the im- 
portance of localized inflammation of the peritoneum, and to the fact 
that many of the supposed cases of cellulitis were really peritonitic, 
by Bernutz. There can be no doubt that he here made an enormous 
step in advance. Like many authors, however, he rode his hobby a 
little too hard, and he erred in denying the occurrence of cellulitis in 
many cases in which it undoubtedly exists. 

Etiology. — The great influence of childbirth in producing these dis- 
eases has long been fullv recognized. Courtv estimates that about two- 
thirds of all the cases met with occur in connection with delivery or 
abortion, and Duncan found that out of 40 carefully selected cases 25 
were associated with the puerperal state. 

It is pretty generally admitted by most modern writers that both 
varieties of the disease are produced by the extension of inflammation 
from either the uterus, the Fallopian tubes, or the ovaries. This point 
has been especially insisted on by Duncan, who maintains that the 
disease is never idiopathic, and is " invariably secondary either to 
mechanical injury, or to the extension of inflammation of some of the 
pelvic viscera, or to the irritation of noxious discharges through or 
from the tubes or ovaries.'' 

Their intimate connection with puerperal septicaemia is also a prom- 
inent fact in the natural history of the diseases. Barker mentions a 
curious observation illustrative of this, that when puerperal fever is 
endemic in the Bellevue Hospital, in Xew York, cases of pelvic peri- 
tonitis and cellulitis are also invariably met with. Olshausen has also 
remarked that in the Lying-in Hospital at Halle, during the autumn 
vacation, when the patients are not attended by practitioners, and when, 
therefore, the chance of septic infection being conveyed to them is less, 
these inflammations are almost always absent. As inflammation of the 
lining membrane of the uterus, of the vaginal mucous membrane, and 
of the pelvic connective tissue are of very constant occurrence as local 
phenomena of septic absorption, the connection between the two classes 



682 THE PUERPERAL STATE. 

of cases is readily susceptible of explanation. Schroeder, indeed, goes 
further, and includes his description of these diseases under the head 
of puerperal fever. They do not, however, necessarily depend upon 
it ; for, although it must be admitted that cases of this kind form a 
large proportion of those met with, others unquestionably occur which 
cannot be traced to such sources, but are the direct result of causes 
altogether unconnected with the inflammation attending on septic 
absorption, such as undue exertion shortly after delivery, or premature 
coition. Mechanical causes may beyond doubt excite the disease in a 
woman predisposed by the puerperal process, but they cannot fairly be 
included under the head of puerperal fever. 

Seat of the Inflammation in Pelvic Cellulitis. — Abundance of 
areolar tissue exists in connection with the pelvic viscera, which may 
be the seat of cellulitis. It forms a loose padding between the organs 
contained in the pelvis proper, surrounds the vagina, the rectum, and 
the bladder, and is found in considerable quantity between the folds of 
the broad ligaments. From these parts it extends upward to the iliac 
fossae and the inner surface of the abdominal parietes. In any of these 
positions it may be the seat of the kind of inflammation we are dis- 
cussing. The essential character of the inflammation is similar to that 
which accompanies areolar inflammation in other parts of the body. 
There is first an acute inflammatory oedema, followed by the infiltra- 
tion of the areolae of the connective tissue with exudation, and the con- 
sequent formation of appreciable swellings. These may form in any 
part of the pelvis. Thus we may meet with them — and this is a very 
common situation — between the folds of the broad ligaments, forming 
distinct hard tumors, connected with the uterus and extending to the 
pelvic walls, their rounded outlines being readily made out by bi- 
manual examination. If the cellulitis be limited in extent, such a 
swelling may exist on one side of the uterus only, forming a rounded 
mass of varying size and apparently attached to it. At other times 
the exudation is more extensive, and may completely or partially sur- 
round the uterus, extending to the cellular tissue between the vagina 
and rectum or between the uterus and the bladder. In such cases the 
uterus is imbedded and firmly fixed in dense, hard exudation. At other 
times the inflammation chiefly affects the cellular tissue covering the 
muscles lining the iliac fossae. There it forms a mass easily made out 
by palpation, but on vaginal examination little or no trace of the 
exudation can be felt, or only a sense of thickness at the roof of the 
vagina on the same side as the swelling. 

Seat of the Inflammation in Pelvic Peritonitis. — In pelvic peri- 
tonitis the inflammation is limited to that portion of the peritoneum 
which invests the pelvic viscera. Its extent necessarily varies with 
the intensity and duration of the attack. In some cases there may be 
little more than irritation, while more often it runs on to exudation of 
plastic material. The result is generally complete fixation of the 
uterus and hardening and swelling in the roof of the vagina, and the 
lymph poured out may mat together the surrounding viscera, so as to 
form swellings, difficult, in some cases, to differentiate from those re- 
sulting from cellulitis. On post-mortem examination the pelvic viscera 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 683 

are found extensively adherent, and the agglutination may involve the 
coils of the intestine in the vicinity, so as sometimes to form tumors of 
considerable size. 

Relative Frequency of the Two Forms of Disease. — The relative 
frequency of these two forms of inflammation as puerperal affections 
is not easy to ascertain. In the non-puerperal state the peritonize 
variety is much the more common, but in the puerperal state they very 
generally complicate each other, and it is rare for cellulitis to exist to 
any great extent without more or less peritonitis. 

Symptomatology. — The earliest symptom is pain in the lower part 
of the abdomen, which is generally preceded by rigor or chilliness. 
The amount of pain varies much. Sometimes it is comparatively 
slight, and it is by no means rare to meet with patients who are the 
subjects of very considerable exudations who suffer little more than a 
certain sense of weight and discomfort at the lower part of the abdo- 
men. On the other hand, the suffering may be excessive, and is char- 
acterized by paroxysmal exacerbations, the patient being comparatively 
free from pain for several successive hours, and then having attacks of 
the most acute agony. Schroeder says that pain is always a symptom 
of peritonitis, and that it does not exist in uncomplicated cellulitis. 
The swellings of cellulitis are certainly sometimes remarkably free 
from tenderness, and I have often seen masses of exudation in the iliac 
fossa? which could bear even rough handling. On the other hand, 
although this is certainly more often met with in non-puerperal cases, 
the tenderness over the abdomen is sometimes excessive, the patient 
shrinking from the slightest touch. The pulse is raised, generally from 
100 to 120, and the thermometer shows the presence of pyrexia. Dur- 
ing the entire course of the disease both these symptoms continue. The 
temperature is often very high, but more frequently it varies from 100° 
to 104°, and it generally shows more or less marked remissions. In 
some cases the temperature is said not to be elevated at all, or even to 
be subnormal, but this is certainly quite exceptional. Other signs of 
local and general irritation often exist. Among them, and most dis- 
tinctly in cases of peritonitis, are nausea and vomiting, and an anxious, 
pinched expression of the countenance, while the local mischief often 
causes distressing dysuria and tenesmus. The latter is especially apt 
to occur when there is exudation between the rectum and vagina which 
presses on the bowel. The passage of feces, unless in a very liquid 
form, may then cause intolerable suffering. 

Such symptoms may show themselves within a few days after 
delivery, and then they can barely fail to attract attention. On the 
other hand, they may not commence for some weeks after labor, and 
then they are often insidious in their onset and apt to be over- 
looked. It is far from rare to meet with cases six weeks or more after 
confinement in which the patient complains of little beyond a feeling 
of malaise and discomfort, and in which, on investigation, a consider- 
able amount of exudation is detected which had previously entirely 
escaped observation. 

Results of Physical Examination. — On introducing the finger 
into the vagina it will be found to be hot and swollen, in some cases 



684 THE PUERPERAL STATE. 

distinctly oedematous, and on reaching the vaginal cul-de-sac the exist- 
ence of exudation may generally be made out. The amount of this 
varies much. Sometimes, especially in the early stage of the disease, 
there is little more than a diffuse sense of thickness and induration at 
either side of, or behind, the uterus. More generally, careful bimanual 
examination enables us to detect a distinct hardening and swelling, 
possibly a tumor of considerable size, which may apparently be attached 
to the sides of the uterus and rise above the pelvic brim, or may extend 
quite to the pelvic walls. The examination should be very carefully 
and systematically conducted with both hands, so as to explore the 
whole contour of the uterus before, behind, and on either side, as well 
as the iliac fossae ; otherwise a considerable exudation might readily 
escape detection. 

When the exudation is at all great, more or less fixity of the 
uterus is sure to exist, and this is a very characteristic symptom. 
The womb, instead of being freely movable by the examining finger, 
is firmly fixed by the surrounding exudation, and in severe forms 
of the disease is quite incased in it. More or less displacement 
of the organ is also of common occurrence. If the swelling be limited 
to one side of the pelvis or to Douglas's space, the uterus is displaced 
in the opposite direction, so that it is no longer in its usual central 
position. 

The differential diagnosis of pelvic cellulitis and pelvic peritonitis 
cannot always be made, and indeed in many cases it is impossible, 
since both varieties of disease coexist, The elements of differentiation 
generally insisted on are, the greater general disturbance, nausea, etc., 
in pelvic peritonitis, with an earlier commencement of the symptoms 
after labor. The swellings of pelvic peritonitis are also more tender, 
Avith less clearly defined outline than those of cellulitis. When the 
cellulitis involves the iliac fossa the diagnosis is, of course, easy, and 
then a continuous retraction of the thigh on the affected side (an in- 
voluntary position assumed with the view of keeping the muscles 
lining the iliac fossa at rest) is often observed. When the inflam- 
mation is chiefly limited to the cavity of the pelvis, the distinction 
between the two classes of cases cannot be made with any degree of 
certainty. 

Terminations. — Both forms of disease may end either in resolution 
or in suppuration. In the former case, after the acute symptoms have 
existed for a variable time, it may be for a few days only, it may be 
for many weeks, their severity abates, the swellings become less tender 
and commence to contract, become harder, and are gradually absorbed, 
until at last the fixity of the uterus disappears and it again resumes 
its central position in the pelvic cavity. This process is often very 
gradual. It is by no means rare to find a patient, even some months 
after the attack, Avhen all acute symptoms have long disappeared, who 
is even able to move about without inconvenience, in whom the uterus 
is still immovably fixed in a mass of deposit, or is at least adherent 
in some part of its contour. More or less permanent adhesions are 
of common occurrence, and give rise to symptoms of considerable 
obscurity, which are often not traced to their proper source. 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 685 

Symptoms of Suppuration. — When the inflammation is about to 
terminate in suppuration, the pyrexia] symptoms continue, and event- 
ually well-marked hectic is developed, the temperature generally show- 
ing a distinct exacerbation at night. At the same time rigors, loss of 
appetite, a peculiar yellowish discoloration of the face, and other signs 
oi suppuration, show themselves. The relative frequency of this ter- 
mination is variously estimated by authors. Duncan quoted Simpson 
as calculating it to occur in half the cases of pelvic cellulitis, but 
stated his own belief that it is much more frequent. West observed it 
in 2o out of 43 cases following delivery or abortion, and McClintock 
in 37 out of 70. Schroeder said that lie had only once seen suppura- 
tion in 92 cases of distinctly demonstrable exudation, a result which is 
certainly totally opposed to common experience. Barker also stated 
that in his experience suppuration in either pelvic peritonitic or cellu- 
litis " is very rare, except when they are associated with pyaemia or 
puerperal fever." It is certain that suppuration is more likely to 
occur in pelvic cellulitis than in pelvic peritonitis, but it unquestion- 
ably occurs, in Great Britain at least, much more frequently than the 
statements of either of these authors would lead us to suppose. 

Channels through which Pus may Escape. — The pus may find 
an exit through various channels. In pelvic cellulitis, more especially 
when the areolar tissue of the iliac fossa is implicated, the most com- 
mon site of exit is through the abdominal wall. It may, however, 
open at other positions, and the pus may find its way through the 
cellular tissue and point at the side of the anus or in the vagina, or it 
may take even a more tortuous course and reach the inner surface of 
the thigh. Pelvic abscesses not uncommonly open into the rectum or 
bladder, causing very considerable distress from tenesmus or dysuria. 
According to Hervieux, it is chiefly the peritoneal varieties which open 
in this way. Not unfrequently more than one opening is formed; and 
when the pus has burrowed for any distance long fistulous tracts result 
which secrete pus for a length of time and are very slow to heal. 
Rupture of an abscess into the peritoneal cavity, especially of a peri- 
tonitic abscess, is a possible (but fortunately a very rare) termination, 
and will generally prove fatal by producing general peritonitis. In 
one case which I have recorded in the fifteenth volume of the Obstet- 
rical Transactions, suppuration was followed by extensive necrosis of 
the pelvic bones. Two similar cases are related by Trousseau in his 
Clinical Medicine, but I have not been able to meet with any other 
examples of this rare complication, which was probably rather the 
result of some obscure septicemic condition than of extension of the 
inflammation. 

Prognosis. — The prognosis is favorable as regards ultimate recovery, 
but there is great risk of a protracted illness which may seriously im- 
pair the health of the patient, especially if suppuration result. Hence 
it is necessary to be guarded in an expression of opinion as to the con- 
sequences of the disease. Secondary mischief is also far from unlikely 
to follow, from the physical changes produced by the exudation, such 
as permanent adhesions or malpositions of the uterus, or organic alter- 
ations in the ovaries or Fallopian tubes. 



686 THE PUERPERAL STATE. 

Treatment. — In the treatment of both forms of disease the impor- 
tant points to bear in mind are the relief of pain and the necessity of 
absolute rest ; and to these objects all our measures must be subordinate, 
since it is quite hopeless to attempt to cut short the inflammation by 
any active medication. 

If the disease be recognized at a very early stage, the local abstrac- 
tion of blood by the application of a few leeches to the groin or to the 
hemorrhoidal veins may give relief; but the influence of this remedy 
has been greatly exaggerated, and when the disease is of any standing 
it is quite useless. Leeches to the uterus, often recommended, are, I 
believe, likely to do more harm than good (unless in very skilful 
hands), from the irritation produced by passing the speculum. Opiates 
in large doses may be said to be our sheet-anchor in treatment when- 
ever the pain is at all severe, either by the mouth, in the form of 
morphia suppositories, or injected subcutaneously. In the not un- 
common cases in which pain comes on severely in paroxysms, the 
opiates should be administered in sufficient quantity to lull the pain ; 
and it is a good plan to give the nurse a supply of morphia supposi- 
tories (which often act better than any other form of administering the 
drug), with directions to use them immediately the pain threatens to 
come on. When there is much pyrexia large doses of quinine may be 
given with great advantage along with the opiates. The state of the 
bowels requires careful attention. The opiates are apt to produce con- 
stipation, and the passage of hardened feces causes much suffering. 
Hence it is desirable to keep the bowels freely open. Nothing answers 
this purpose so well as small doses of castor oil, such as half a tea- 
spoonful given every morning. Warmth and moisture constantly 
applied to the lower part of the abdomen give great relief, either in 
the form of large poultices of linseed-meal, or, if these prove too heavy, 
of spongio-piline soaked in boiling water. The poultices may be 
advantageouslv sprinkled with laudanum or belladonna liniment. I 
say nothing of the use of mercurials, iodide of potassium, and other 
so-called absorbent remedies, since I believe them to be quite valueless 
and apt to divert attention from more useful plans of treatment. 

The most absolute rest in the recumbent position is essential, and it 
should be persevered in for some time after the intensity of the 
symptoms is lessened. The beneficial effect of rest in alleviating pain 
is often seen in neglected cases, the nature of which has been over- 
looked, instant relief following the laying up of the patient. 

When the acute symptoms have lessened, absorption of the exuda- 
tion may be favored and considerable relief obtained from counter- 
irritation, which should be gentle and long-continued. The daily use 
of tincture of iodine until the skin peels, perhaps best meets this indi- 
cation, but frequently repeated blisters are often very serviceable. 
This I believe to be a better plan than keeping up an open sore with 
savine ointment or similar irritating applications. 

When suppuration is established, the question of opening the abscess 
arises. When this points in the groin and the matter is superficial, a 
free incision may be made, and here, as in mammary abscess, the anti- 
septic treatment is likely to prove very serviceable. The abscess 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 687 

should, however, not be opened too soon, and it is better to wait until 
the pus is near the surface. The importance of not being in too great 
a hurry to open pelvic abseesses has been insisted on by West, Duncan, 
and other writers, and I have no doubt the rule is a good one. It is 
more especially applicable when the abscess is pointing in the* vagina 
or rectum, where exploratory incisions are apt to be dangerous, and 
when the presence of pus should be positively ascertained before 
operating. We have in the aspirator a most useful instrument in the 
treatment of such cases, which enables us to remove the greater part 
of the pus without any risk, and the use of which is not attended 
with danger, even if employed prematurely. If it does not sufficiently 
evacuate the abscess, a free opening can afterward be safely made and 
a suitable drainage-tube inserted into the abscess cavity. The surgical 
treatment of pelvic abscess is, however, too wide a subject to admit of 
being satisfactorily treated here. 

The diet should be abundant, but simple and nutritious. In the 
early stages of the disease, milk, beef-tea, eggs, and the like will be 
sufficient. After suppuration a large quantity of animal food is neces- 
sary, and a sufficient amount of stimulants. The drain on the system 
is then often very great, and the amount of nourishment patients will 
require and assimilate, when a copious purulent discharge is going on, 
is often quite remarkable. A general tonic plan of medication is 
also indicated, and such drugs as iron, quinine, and cod-liver oil will 
prove useful. 



INDEX 



ABDOMINAL gestation, 179, 181 
pregnancy, 191 
Abortion and premature labor, 252 

causes of, 254 

definition of, 253 

importance and frequency of r 252 

most common in multipara 3 , 253 

of artificial, 207 

production of, 417 

symptoms of, 258 

subsequent management of, 264 

treatment of, 259 

tubal, 183 
Abscess, mammary, 596 
After-pains, 277, 582 

treatment of severe, 583 

-coming head, perforation of, 528 
Ala vespertilionis, 70 
Albumin in urine of pregnant women, 212 

predisposes to abortion, 214 
Albuminuria, prognosis of, 214 

of pregnancy, induction of premature 
labor in, 216 

symptoms of, 215 

treatment of, 215 
Allantois, 110 
Amnion, 112 

diagnosis of, 246 

formation of, 108 

pathology of, 245 

treatment of, 246 
Ansemia and chlorosis in affections of re- 
spiratory organs, 211 
Anaesthesia in labor, 308 
Anaesthetics, question of administering, 

502, 546 
Anatomy and physiology of foetus, 122 
Ante-partum hour-glass contraction, 371 
Anteversion, 223 
Antipyrine in pregnancy, 206 
Area germinativa, 107 

pellucida, 107 
Arm, dorsal displacement of, 345 

presentation, cases of, 492 
Arterial thrombosis and embolism, 668 
causes of, 668 
symptoms of, 669 
treatment of, 670 
Articulations, pelvic, 36 
Artificial dilatation, 368 
Auscultatory signs of pregnancy, 158 



BALLOTTEMENT in pregnancy, 157 
Belladonna in pregnancy, 206 
[Binder, time to apply, 302, 303, 306] 
Births, frequency of multiple, 173 
plural, 379 
treatment of, 380 
Bladder, irritability of, 220 
Blood, defibrination of, 568, 572 
injection of, 573 

in pregnancy, composition of, 145 
[transfusion of, 564, 574] 

Aveling's method of, 566 
history of, 564 
nature and object of, 565 
Boussel's method of, 567 
Schafer's method of, 567, 571 
Body, extraction of, 534 
Bowels, action of, 585 
[Breech forceps, 322] 

[position, important to change to ver- 
tex, 314] 
Brim, contracted, 406 
Broad ligaments of uterus, 69 
Brow presentations, 332 



pADUCA, 102 

\J [Csesarean section, in the U. S., 370] 
[danger of, in the U. S., 417] 
[elective, 541] 
[for transverse positions in 

the U. S., 344, 345] 
[history of, 537, 552] 
[horn-rips, 537, 538] 
[in cancer of cervix in the 

U. S., 370] 
[in Europe, 539] 
[in pelvic exostosis, in the 
• U. S., 405] 
[in 1893, 551, 552] 
Calculus, vesical, 375 
Caput succedaneum, formation of, 289 
Carcinoma, 231 

Cardiac murmurs in pulmonarv obstruc- 
tion, 664 
Carunculae myrtiformes, 53 
Cellulitis, pelvic, 680 
Cephalalgia as a cause of albumin in urine, 

214 
Cephalic version, 479 
Cephalotribe, 524 
44 (689) 



690 



INDEX, 



Cephalotripsy and craniotomy, compara- 
tive merits of, 530 
Cervix, cavity of, 59 

changes in, during pregnancy, 142 

mucous membrane of, 64 

rigidity of, 366 

softening of, 157 
Chapman's spinal ice-bag, 206 
Child, clothing of, 589 

examination of, 323 

expulsion of, 267, 301 

management of suckling of, 591 

over-frequent suckling of, 589 

position of, at brim, 315 

risk to, 405 

washing and dressing of, 588 
Childbirth, management of women after, 
582 _ 

mortality of, 575 
Chloral in pregnancy, 206 
[Chloroform inhalation, objected to in the 

U. S., 311] 
Chorea in first pregnancy, 218 

prognosis of, 219 

treatment of, 219 
Chorion,, disease of, 237 
causes of, 237 
pathology of, 237, 238 
progress of, 239 
symptoms of, 239 
treatment of, 240 

hydatidiform degeneration of, 237 
Circulation of foetus, 134 
[Clay-eating, producing pelvic obstruction 

in Southern U. S., 376] 
Cleanliness, attention to, 584 
Clitoris, 51 

Coagulation in puerperal state, 658 
Cocaine in pregnancy, 206 
Coccyx, anatomy of, 36 

ligaments of, 37 
Coelio-elytrotorny, 553 

cases suitable for, 554 
history of, 553 
nature of operation of, 554 
operation of, 553 
Cceliotomy, 655 

mode of performing secondary, 197 
[Color-line of abdomen in pregnancy, 155] 
Conception and generation, 96 

fruitful, signs of, 150 

mental peculiarities in, 152 

morning sickness a sign of, 151 
Constipation in pregnancy, 208 
Continued fevers, 228 
Cough, spasmodic, 210 
Cow's milk and its preparation, 600 
[Coxalgia, causing pelvic deformity, 402] 
Cranioclast, 524 
Craniotomy, cases requiring, 526 

religious objections to, 522 

when justifiable, 528 
Cross-births, 337 
Crural phlebitis, 675 
Culbute, 128 



Curetting the uterine cavity, 651 

Curve, pelvic, 496 

Cyst, formation of, around ovum, 191 

opening, by caustics, 1 97 
Cystic disease of ovum, 237 
Cystocele, vaginal, 375 



DECAPITATION, 522, 535 
Decidua. 102 

pathology of, 234 
Deformities of pelvis, 391, 394 
causes of, 392 
classification of, 391 
Delivery, alterations in blood after, 576 
[instance of rapid natural, 365] 
instrumental, 361 
probable date of, 168 
signs of recent, 171 
Diabetes in pregnancy, 216 
Diarrhoea in pregnancy, 208 
Diet and regimen, 583 
Digestive system, derangements of, 204 
disorders of, in pregnancy, 208 
Dilatation, 273 

artificial, 368 
Discus proligerus, 80 
Dizziness as a cause of albumin in urine. 

214 
Dorsal displacement of arm, 345 
Double monsters, 382 

division of, 384 
Douches, vaginal and uterine, 475 
Dropsical effusions, 389 
Dyspnoea in earlv months of pregnancy, 

210 
Dystocia in labor, 390 

treatment of, 391 



T ECLAMPSIA, 612] 

LIj Ecraseur, 526 

Emboli, detachment of, 677 

Embryotomy, 323, 535 

Endochorion, 114 

Endometritis decidualis polyposa, 235 

tuberosa, 235 
Epilepsy, 229 
Eruptive fevers, 227 
Erysipelas, infection from, 631 
Evisceration, 522, 535, 536 
Evolution, spontaneous, 342 
Exochorion, 114 
Expressio foetus, 359 
Extra-uterine pregnancy, 179 

condition of uterus in, 184 

etiology of, 181 
Eye, diseases of, 230 



FACE presentations, 323 
descent in, 327 
extension in, 327 
liexion in, 328 
four positions met with in, 326 



INDEX. 



691 



Face presentations — 

frequency of, 324 
mechanism of, 325 
prognosis of, 330 
rotation in, 327 

external, 328 
treatment of, 330 
-to-pubes delivery, causes of, 333 
treatment of, 334 
Fallopian tubes, 72 
Fa rail ic current, use of, 359 
Fatty transformation of muscular fibres, 

579 
Female generative organs, 49 
Fevers, continued, 228 

eruptive, 227 
Fibroid tumors, 233 
Figure-of-eight deformity, 397 
Fillet, 521 

Foetal head, anatomy of, 125 
heart-sounds, 159 
membranes and placenta, arrangement 

of, 175 
movements in pregnancy, 155 
skull, diameters of, 126 
tumors obstructing delivery, 390 
[Foetus, always small, with some women, 
124] 
anatomy and physiology of, 122 
appearances of, at various stages of 

growth, 122 
at term, 124 
circulation of, 134 
death of, 192, 251 
diagnosis of, 252 
symptoms of, 252 
destruction of, 521 

operations involving, 521 
functions of, 131 
means of destroying, 189 
pathology of, 247 
position of, 337 

found by palpation, 129 
respiration of, 133 
wounds and injuries of, 249 
Foetuses, size of, in multiple pregnancies, 

174 
Food and stimulants, administration of, 

652 
Foot, bringing down, 322 
Forceps, 322, 412, 494 
action of, 500 

antiseptic precautions in use of, 503 
application of, within cervix, 370 

to after-coming head, 321 
Continental, 498 
[craniotomy, Meigs's, 534, 535] 
crochets and craniotomy, 523 
description of, 494 
dynamical action of, 501 
extraction by craniotomy, 533 
Hodge, 511 

[in America, 509, 519] 
long, 497 
method of applying, 502 



Forceps — 

mode of introducing lower blade, 504 
upper blade, 505 
blades in high forceps opera- 
tions, 508 
possible dangers of delivery by, 508 
Sawyer, 513 
section of skull by, 526 
short, 495 

Simpson's axis-traction, 499 
Tarnier's, 499 
use of, in modern practice, 494 

possible dangers attending, 362 
Zeigler's, 496 
Fossa navicularis, 53 
Fractures, deformity from, 404 
Funic souffle, 161 



GALACTOPHOKOUS ducts, 81 
General modifications in body pro- 
duced by pregnancy, 145 
Generative organs in female, 49 
Gestation, abdominal, diagnosis of, 193 
treatment of, 194, 198, 200 
in a bi-lobed uterus, 198 
Glands, mammary, 80 
vulvo-vaginal, 53 
Graafian follicles, 7 7, 79 
changes in, 83 
Greenhalgh's pelvimeter, 410 
Groin, traction on, 322 



HEMATIC effusions, 376 
symptoms of, 377 
treatment of, 377 
Hand-feeding, 599 

method of, 602 
Harris's symphyseotomy bistoury, 561 
Head, birth of, 320 
delivery of, 317 

position of, mode of recognizing, 279 
presentations, delivery in, 406 

four positions described, 279, 289 
mechanism of delivery in, 278 
shape of, from moulding, 290 
Hearson's thermostatic nurse, 478 
Heart disease, 228 
Hemorrhage, 430 

[after delivery, treated by position of 

woman, 445] 
after rupture of vein, 222 
before delivery, 418 
causes of, 430 
constitutional causes, 448 
curative treatment of, 439 
definition of, 430, 433 
diagnosis of, 431 
differential diagnosis of, 432 
from laceration of maternal structures, 

446 
importance of, 433 
local causes, 448 
pathology of, 430 



692 



INDEX. 



Hemorrhage — 

post-partum, 433, 447 

preventive treatment of, 438 

prognosis of, 432 

secondary, 447 

symptoms of, 431 

treatment of, 432, 449 
Hemorrhoids in pregnancy, 209 
Hernial protrusion, 375 
Heterogenetic infection, source of, 630 
Hip-joint disease, 404 
Hour-glass contractions, 436 

treatment of, 441 
[Hydramnios, 245, 246] 
Hydrocephalus, intra-uterine, 387 
Hydroperione, 105 
Hydrorrhea gravidarum, 236 
[Hysterectomy, supra-vaginal, when not a 
Porro operation, 458] 



TCE-BAGS in pregnancy, 206 
1 Idiopathic asphyxia, 670 
Impregnation, 99 

sites of, 98 
Incontinence of urine, 220 
Induction of premature labor, 469 

history of, 469 

operation of, 469 

puncture of membranes in, 
471 

various methods of, 471 
Infant, management of, 586 
Infantile mortality, effect of early inter- 
ference on, 362 
Infection from erysipelas, 631 
Injection of saline solutions, 569 
Insanity of lactation, 618 

puerperal, 612, 615 
Instrumental delivery, 361 
Interstitial and false ovarian pregnancv, 

185 
Intestines, scybalous masses in, 376 
Intra-uterine hydrocephalus, 387 

diagnosis of, 388 

treatment of, 389 
Irregular and spasmodic pains, 356 
Irritability of bladder, 220 
[Ischio-pubiotomy, unilateral, 563] 



JAUNDICE, simple, 230 
Joint, lumbo-sacral, 36 



LABIA majora, 49 
minora, 50 
Labor, abortion and premature, 252 
after-treatment of, 307 
anaesthesia in, 308 
antiseptic precautions in, 292 
attention to cleanliness in, f.94 
causes of, 265 
chloral in, 308 
chloroform in, 308, 309 



Labor — 

complicated with tumor, 372 

course of, 406 

delay in first stage of, 353 

division of, into stages, 272 

duration of, 277 

duties on first visiting patient in, 292 

effects of prolongation of, 367 

ether in, 308, 310 

false pains in, 294 

first summons in, 291 

[induced prematurely, mortality in, 
477] 

induction of premature, 469 

management of natural, 290 

management of third stage of, 302 

methylene in, 308 

[missed, 198, 201-203] 

mode of conducting vaginal examina- 
tion in, 295 

objections to theories of, 267 

obstructed by faulty condition of soft 
parts, 366 

pains during, 271 

phenomena of, 265 

position of patient during first stage 
of, 296 
second stage of, 297 

precipitate, 351 

preparatory treatment in management 
of, 290 

prolonged, 351 

protraction in second stage of, 353 

stage of, first, 273 

premonitory, 273 
preparatory, 272 
second, 274 
third, 275 

treatment, 367 

true pains in, 294 

use of antiseptic injections in, 293 

vaginal examinations in, 294 
Laceration of veins, 222 
Lactation, 585 

disorders of, 593 

insanity of, 618 

signs of successful, 592 
Laminae dorsales, 107 
Leeches in pregnancy, 206 
Leipothymia, 211 
Leucorrhoea, 220 
Ligaments of coccyx, 57 
Liquor amnii, deficiency of, 246 
Lithopaedion, 193 
Liver, changes in, 148 

function of, 136 
Lochial discharge, 581 
Locked twins, difficulties arising from, 381 
Lumbo-sacral joint, 36 



MALPRESENTATION, frequency of, 
406 
Mammary abscess, 596 

method of opening, 597 



INDEX 



693 



Mammary abeoe 

treatment of, 597 

glan.: 
Mania during delivery, transient, 615 

puerperal, 612 
Maturation, 
Measles, 228 

Mechanism of delivery in head presenta- 
tions. 278 
Membrane, sub-zonal. 108, 114 
Membranes, management of, 306 

puncture of. 425 

rupture of, 4>> 

separation of, 475 
Menstruation, 86 

cessation of, 94 
period of. 94 

cyclical theory of, 93 

duration o( period of, 89 

influence of climate on. 87 
of cold on, S7 

law in reference to, 93 

theory of, 62. 91 
Menthol in pregnancy, 206 
Milk, artificial human, 600 

[as a diet for nursing mothers, 594] 

cow's, 600 

excessive flow of, 595 

secretion of, means of arresting, 593 
defective. 593 

transfusion of, 569 
Miscarriage. 253 
Missed labor, 193 
Mole, fleshy, 255 

vesicular 23- 
Monsters, double. 352. 3S4 
Mons Veneris. 49 
Morphia in pregnancy, 206 
Mother, diseases transmitted through. 247 

risk to. 405 
Myxoma tibrosum of placenta, 240 



VEEYOUS system, changes in, 147 
ll disorders of, 217 

function of, 137 
Neuralgia in preenancy, 210 
Newborn child, apparent death of| 586 

treatment after death of, 587 
Nipple. SI 
Nipples, depressed, 594 

fissures and excoriations of, 594 
Nursing women, diet of, 592 
Nutrition. 132 



OBTURATOR membrane, 37 
Oecipito-posterior positions, 333 
Occiput, rotation of, forward, 2^7 
(Edema of lower limbs, 221 

of vulva, 376 
Oldham's vertebral hook, 523 
Operations, high forceps. 507 
Organic changes, rigidity depending upon, 
368 



I >- innominatum. 33 
occlusion of, 370 
uteri, artificial dilatation of, 473 
Osteomalacia, 392 

deformity from, 

frequencv of, 393 

[rare in the U. S, 393] 
Osteophytes, formation of, 147 
Ovarian tumor, 231 
Ovaries. 74 

tumors of, 373 
Ovary, functions of, 82 

structure of, 75 
Ovulation and menstruation. s 2 
Ovule, 79 

escape of. S3 
Ovum, cystic disease of. 237 

formation of cvst around, 191 

pathology of, 234 
Oxalate of cerium in pregnancy. 206 
Oxytocic remedies, 357 
Oxytocics, administration of, 472 



PAINS during labor, 271 
effect of, on mother and foetus, 272 
irregular and spasmodic, 356 
value of intermittent character of. 270 
Palpation due to svmpathetic disturbance, 

211 
Pampiniform plexus. 66 
Paralysis in pregnancy. 217 

puerperal, 218 
Parturient canal, axis of, 44 
Pelvic articulations, 36 
cellulitis, 6S0 

differential diagnosis of, 684 
etiology of, 681 
prognosis of, 685 
relative frequency of, 683 
results of phvsical examination 

of, 683 
seat of, 681 

symptomatology of. 653 
symptoms of suppuration of, 685 
terminations of, 684 
treatment of, 686 
variety of nomenclature, 680 
joints, movements of, 35 
peritonitis, 680 
presentations, 312 
causes of, 312 
diagnosis of, 313 
frequency of, 312 
prognosis of. 312 
mechanism oi\ 315 
treatment of, 319 
Pelvis, anatomy of, 33 
eavin of. 46 
contracted, 407 

diagnosis of. 40S 
treatment of, 411 
[deformed, symphyseotomy in, 415] 
deformities of, 391, 394 
deformity of, 452 



694 



INDEX, 



Pelvis — 

development of, 46 
in different races, 48 
measurements of, 41 
obliquely contracted, 401 
planes of, 43 
Kobert's, 403 

soft parts in connection with, 48 
[sometimes very small in large women, 
394] 
Perineum, 53 

distention of, 299 
examination of, 307 
extreme rigidity of, 371 
incision of, 300 
relaxation of, 299 
support of, 299 
Period of day at which labor occurs, 278 
Peripheral thrombosis, 673 
history of, 674 
pathology of, 674 
period of commencement of, 674 
progress of, 674 
symptoms of, 673 
treatment of, 677 
Peritonitis, pelvic, 680 
[Phlebitis, crural, after Porro-Caesarean 

and Cesarean sections, 676] 
Phlegmasia dolens, 673 
Phthisis, 228 
Placenta, adherent, 441 

treatment of, 441 
adhesions, 437 
battledore, 244 
double, 242 

entire separation of, 427 
expression of, 303 
fatty degeneration of, 243 
form of, 115 
functions of, 120 
membranacea, 241 
pathological changes in, 422 
pathology of, 241 
polypus, 263 
praevia, 418 

causes of, 418 
definition of, 418 
history of, 418 
prognosis of, 423 
symptoms of, 419 
treatment of, 424 
signs of adherent, 441 
souffle, 162 
succenturise, 241 
Placentitis, 241 
Planes of pelvis, 43 
Pneumonia, 228 
[Polypus uteri as an obstruction to labor, 

378] 
Porro-Csesarean operation, 549 

[in fibroid obstruction, 373] 
Precipitate labor less common than linger- 
ing, 365 
labors, 351 

treatment of, 366 



Pregnancies, multiple, in Europe, 173 
Pregnancy, 137 

abdominal, 191 

excision of cyst in, 196 

mode of performing operation in, 
195 

treatment of, 196 
abnormal, 173 

appearance of breasts in, 153 
auscultatory signs of, 158 
ballottement as a sign of, 157 
classification of signs of, 150 
composition of blood in, 145 
constipation in, 208 
diabetes in, 216 
diagnosis of, 187 
diarrhoea in, 208 
differential diagnosis of, 164 
diseases coexisting with, 227 
diseases of, 203 
dress of patient during, 291 
duration of, 167 
extra-uterine, 179 

classification of, 179 
etiology of, 181 
false ovarian, 185 
foetal movements in, 155 
general modifications in body pro- 
duced by, 145 
hemorrhoids in, 209 
insanity of, 613 

causes of, 616 

duration of, 618 

forms of, 614 

judicious nursing in, 622 

post-mortem signs of, 618 

prognosis of, 615, 618 

symptoms of, 619 

treatment of. 620, 623 
interstitial, 185 
multiple, diagnosis of, 176 
neuralgia in, 210 
paralysis in, 217 
progress of, 185 
protraction of, 169 
ptyalism in, 209 
rupture of, 185 
signs of, 149 
spurious, 166 
symptoms of, 149, 185 
termination of, 185 
treatment of, 188 
uterine fluctuation in, 158 
vaginal pulsation in, 158 

signs of, 157 
Premature labor, induction of, 415 
Presentations, face, 323 
breech, 312 
complex, 345 
footling, 312 
knee, 312 
pelvic, 312 
transverse, 337 
Princess Charlotte of Wales, death of, 364 
Prolapse of uterus, 222 



INDEX. 



695 



Prolapsed funis, 346 
causes of, 348 

diagnosis of, 348 
frequency of, 347 

prognosis of, 347 
treatment of, 349 
Prolonged labors, 351 

evil effects of, 352 
Propulsion, 274 
Protracted labor, causes of, 354 
treatment of, 356 
Protraction of pregnancy, 169 
Pruritus of vulva, 221 
Ptyalisni in pregnancy, 209 
Puberty, changes occurring at, 88 
Puerperal disease, defective sanitation as a 
cause of, 633 
eclampsia, 603 

as a cause of albumin in urine, 

214 
cause of death in, 606 
doubtful etiology of, 603 
exciting causes of, 608 
obstetric management in, 611 
paroxysms during, 611 
pathology of, 606 
premonitory symptoms of, 604 
treatment of, 609 
fever, administration of turpentine in, 
655 
application of cold in, 654 
difference of opinion as to, 623 
evacuant remedies in, 655 
history of, 624 
modern view of, 624 
mortalitv of, in lving-in hospitals, 

624 
reduction of temperature in, 

653 
theories advanced regarding its 

nature, 626 
theory of its local origin, 626 
treatment of, 655 
insanity, 612 

classification of, 612 
pleuro-pneumonia, 667 

physical signs of, 667 
septicaemia, 623 

description of, 644 
duration of, 645 
pysemic forms of, 647 
symptoms of, 644 
treatment of, 648 
state and its management, 575 

temperature of, 577 
thrombosis, 656 
cases of, 663 
cause of death in, 665 
conditions which favor, 657 
history of, 661 
post-mortem examinations in, 660, 

665 
symptoms of, 661 
treatment of, 665, 668 
[Pullulation, arrested, 251] 



QUICKENING, syncope during period 
of, 2 1 1 
Quinine as an oxytocic, 357 



RESPIRATION, commencement of, 586 
of foetus, 133 

Respiratory organs, affections of, 210 
treatment of, 212 
changes in, 147 
Rest, importance of prolonged, 585 
Retention in utero of a blighted ovum, 263 

of urine, 219 
Retroversion, 223 
causes of, 224 
diagnosis of, 225 
progress of, 224 
symptoms of, 224 
termination of, 224 
treatment of, 225 
Rickets, 392 

frequency of, 393 
mode of production in, 396 
I Robert's pelvis, 403 
\ Round ligaments of uterus, 71 



, O ACKO-ILIAC synchondrosis, 37 
O -sciatic ligaments, 3 i 
Sacrum, anatomy of, 35 

mechanical relations of, 35 
Salicine in pregnancy, 205 
Sanitary arrangements in septicemia, 633 
Saprsemia or self-infection, sources of, 629 
i Scarlet fever, 227 
Scybalous masses in intestines, 376 
Secretions and excretions, 577 
Semen, 96 

ascent of, 98 
Septicaemia from contagion, 634 
prophylaxis of, 637 
puerperal, 623 
surgical, 627 
Septic poison, nature of, 638 
Serous envelope, 114 
Sewer-gas a cause of septicaemia, 633 
Sex of children in twin pregnancies, 174 
Shoulder presentations, 337 
causes of, 338 
diagnosis of, 339 
frequency of, 339 
mechanism of, 341 
prognosis of, 339 
terminations of, 341 
treatment of, 344 
Sites of impregnation, 98 
Softening of cervix, 157 
Spasmodic cough, 210 
Spondylolisthesis, 397 

[origin, etc., rare in the U. S., 399, 
400] 
Spondylolizema, 400 
Spurious pregnancy, 166 
Stage of labor in which delay occurs, 352 
Super fecundation, 176 



696 



INDEX. 



Superfoetation, 176 

Suppuration, treatment of long-continued, 

599 
Symphyseotomy, 553, 557 

description of operation, 560 

Galbiati's knife used in, 560 

history of, 557 

[-knife, Harris's, 561] 

limits of operation of, 558 

progress of, 561 

[and results of, 563] 
Symphysis pubis, 37 

Syncope during period of quickening, 211 
Syphilis, 229 



T ACTUS eruditus, 279 
Tetanoid falciform constriction of 
uterus, 371 
Tetanus in pregnancy, 219 
Thornton's ice-cap, 654 
Thrombosis and embolism, distinction be- 
tween, 659 

puerperal, 656 
Toothache and caries of teeth in preg- 
nancy, 210 
Traction, method of, 505 
Transfusion, secondary effects of, 574 
Tubal abortion, 183 

gestation, 179, 180, 182 
Tumors, deformity from, 404 

of ovaries, 373 
Tumor, labor complicated with, 372 
Tunica albuginea, 75 
Turning, 426 

[bimanual, 429] 

by combined external and internal 
manipulation, 485 

dangers of operation of, 480 

history of, 479 

in abdomino-anterior positions, 492 

in placenta praevia, 491 

method of performance, 483 
[Twins, Carolina, united, 386] 

[duplex, birth of, 384] 

locked, 381 

[united, 387] 



UMBILICAL cord, 121 
pathology of, 244 
prolapse of, 346, 405 
. souffle, 161 
Urethra, 52 

Urinary organs, disorders of, 219 
Urine, changes in, 148 
incontinence of, 220 
in intra-uterine life, 136 
phosphatic condition of, 220 
retention of, 219, 583 
[Uteri, double,' 68] 

Uterine contraction after birth of child, 
301 
at commencement of labor, 269 
fluctuation in pregnancy, 158 



Uterine hydatids, 237 

parietes, changes in, 141 
pressure, special value of, 361 
souffle, 162 

vessels, changes in, 579 
Utero-gestation, period of, 169 

-sacral ligaments, 72 
Uterus, 57 

alterations in tissues of, 452 
anatomy of, 62 
anomalies of, 67 
changes in, 137 
contraction of, 578 
gestation in a bi-lobed, 198 
gravid, anteversion of, 223 

displacements of, 222 

pressure by, 212 

retroversion of, 223 
in protracted labor, 354 
inversion of, 462 

acute and chronic pains, 463 

description of, 463 

differential diagnosis of, 464 

mechanism of, 464 

symptoms of, 463 

treatment of, 466 
ligaments of, 69 

methods acting indirectly on, 472 
partitioned, 69] 
prolapse of, 222 
round ligaments of, 71 
rupture of, 451 

causes of, 452 

prognosis of, 455 

symptoms of, 454 

treatment of, 456 
size of, at various stages of pregnancy, 

140 
[spontaneous reposition of, inverted, 

467, 468] 
value of anaesthesia in relaxing, 493 



VAGINA, 54 
bands and cicatrices in, 371 

contraction of, 580 

lacerations of, 459 

orifice of, 52 

plugging of, 426 
Vaginal cystocele, 375 

examinations. 294 

mode of conducting, 295 

pulsation in pregnancy, 158 

signs of pregnancy, 157 
Vectis, 519 

cases in which applicable, 520 

nature of, 519 
Veins, death from air in, 671 

lacerations of, 222 
Venesection, 652 
[Version by the vertex, 336] 

cephalic, 479 

spontaneous, 342 
Vesical calculus, 375 
Vesicular mole, 237 



INDEX, 



697 



Vestibule, : >l 

Viscera, modifications in certain, 

Vulva, oedema oi', 376 
pruritus of, 221 
vascular supply of, 53 

Vulvovaginal glands, 53 



147 



w 



ALES, death of Princess Charlotte of, 
364 



Weaning, period of, 593 
Wet-nurse, selection of, 590 

[-nurses of the LJ. S., 592] 
[Womanhood, precocious physical, 88] 



ZYMOTIC fever, theory of an essential, 
626 
diseases, infection from, 631 



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its reduction in price from five to Four Dollars per annum. It is now by 
far the cheapest as well as the best large weekly medical journal published 
in America. Employing all the recognized resources of modern journalism, such as the 
cable, telegraph, resident correspondents, special reporters, etc., The News furnishes 
in the 28 quarto pages of each issue the latest and best information on subjects of 
importance and value to practitioners in -all branches of medicine. The foremost writers, 
teachers and practitioners of the day furnish original articles, clinical lectures and notes 

(Continued on next page.) 



2 Medical Periodicals, Visiting List, Ledger. 

THE riEDICAL NEW5===Continued. 

on practical advances; the latest methods in leading hospitals are promptly reported; 
a condensed summary of progress is gleaned each week from a large exchange list, com- 
prising the best journals at home and abroad ; a special department is assigned to abstracts 
requiring full treatment for proper presentation ; editorial articles are secured from 
writers able to deal instructively with questions of the day ; books are carefully 
reviewed; society proceedings are represented by the pith alone; regular correspondence 
is furnished from important medical centres, and minor matters of interest are grouped 
each week under news items In a word The Medical News is a crisp, fresh, weekly 
newspaper and as such occupies a well-marked sphere of usefulness, distinct from and 
complementary, to the ideal monthly magazine, The American Journal of the 
Medical Sciences. 

The American Journal | Published Monthly 

of the J at $4.00 



i 

Medical Sciences * 



Per Annum. 



The American Journal entered with 1893 upon its seventy-fourth year, still main- 
taining the foremost place among the medical magazines of the world. A vigorous 
existence during two and a half generations of men amply proves that it has always 
adapted itself to meet fully the requirements of the time. 

Being the medium chosen by the best minds of the profession during this 
period for the presentation of their ablest papers, The American Journal has well 
earned the praise accorded it by an unquestioned authority — "From this file alone, were all 
other publications of the press for the last fifty years destroyed, it would be possible to reproduce 
the great majority of the real contributions of the world to medical science during that period." 
Original Articles, Eeviews and Progress of the Medical Sciences constitute the three main 
departments of this ideal medical monthly. 



COMMUTATION RATE. 

Taken together, The Journal and The News afford to medical readers the ad- 
vantages of the monthly magazine and the weekly newspaper. Thus all the benefits of 
medical periodical literature can be secured at the low figure of $7.50 per annum. 



Subscribers can obtain, at the close of each volume, cloth covers for The Journal (one 
annually), and for The News (one annually), free by mail, by remitting Ten Cents for The 
Journal cover, and Fifteen Cents for The News cover. 



The Medical News Visiting List for 1893 

Is published in four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 120 
patients per month) ; Perpetual (undated, for 30 patients weekly per year) ; and Per- 
petual (undated, for 60 patients weekly per year). The 60-patient Perpetual consists 
of 256 pages of assorted blanks. The first three styles contain 32 pages of important 
data and 176 pages of assorted blanks. Each style is in one wallet-shaped book, leather- 
bound, with pocket, pencil, rubber, and catheter- scale. Price, each, $1.25. 



This list is all that could be desired. It con- 
tains a vast amount of useful information, especi- 
ally for emergencies, and gives good tables of doses 
and therapeutics. — Canadian Practitioner. 

For convenience and elegance it is not surpass- 
able.— Obstetric Gazette. 



The new issue maintains its previous reputation. 
It adapts itself to every style of book-keeping; 
there is space for all kinds of professional records ; 
it is furnished with a ready reference thumb-letter 
index, and has a most valuable text. — Medical 
Record. 



SPECIAL COMBINATIONS WITH THE VISITING LIST, see p. 1. 

JSgj^The safest mode of remittance is by bank check or postal money order, drawn to 
the order of the undersigned ; where these are not accessible, remittances for subscriptions 
may be sent at the risk of the publishers by forwarding in registered letters addressed to 
the Publishers (see belowj. 

The Medical News Physicians' Ledger. 

Containing 300 pages of fine linen " ledger " paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $4.00. 

Lea Brothers & Co., Publishers, 70S, 708 & 710 Sanborn Street, Philadelphia. 



Medical Dictionary, Quiz Manuals. 

A NEW MEDICAL DICTIONARY. READY SHORTLY. 



DICTIONARY OF MEDIGINE 

AND THE ALLIED SCIENCES, 

COMPRISING THE PRONUNCIATION, DERIVATION AND FULL EXPLANATION OF MEDICAL 

TERMS; TOGETHER WITH MUCH COLLATERAL DESCBEPTTVE MATTER, 

NUMEROUS TABLES, ETC. 

By ALEXANDER DUANE, M. D., 

Assistant Surgeon to the New York Ophthalmic and Aural Institute; Reviser of Medical Terms for 
Webster's International Dictionary. 

In one square octavo volume of about 600 pages. 
This handy volume gives succinct but complete information concerning every word 
likely to be met with by students or physicians in the course of medical reading. Especial 
care has been devoted to making the definitions clear and full, this main service of a 
dictionary being expanded to include much descriptive and explanatoiy matter under 
headings which would be inadequately represented by a definition, however full. Thus, 
under diseases are given their causation, symptoms and treatment; under important 
organs, an outline of their structure and functions ; under each drug its action, uses and 
preparations. Extensive tables of bacilli, muscles, arteries, veins, etc., are included, and 
the pronunciation and derivation of all words are given in a manner to be readily under- 
stood. Each page contains an extraordinary amount of matter set in type of great clear- 
ness and beauty. In every detail Duane's Pronouncing Medical Dictionary has been 
planned to furnish to the student a standard guide to medical terms, on a level with the 
existing advanced condition of the medical sciences. 



THE STUDENTS' QUIZ SERIES. 

ANEW Series of Manuals, comprising all departments of medical science and practice, 
and prepared to meet the needs of students and practitioners. Written by promi- 
nent medical teachers and specialists in New York, these volumes may be trusted as 
authoritative and abreast of the day. They enjoy the unique advantage of issue under 
careful editorial supervision which gives assurance of accuracy, completeness and com- 
pactness. Cast in the form of suggestive questions, and concise and clear answers, the 
text will impress vividly upon the reader's memory the salient points of his subject. 
To the student these volumes will be of the utmost service in preparing for examina- 
tions, and they will also be of great use to the practitioner in recalling forgotten details, 
and in gaining the latest knowledge, whether in theory or in the actual treatment of 
disease. Illustrations have been inserted wherever advisable. Bound in limp cloth, 
and in size suitable for the hand and pocket, these volumes are assured of enormous 
popularity, and are accordingly placed at an exceedingly low price in comparison with 
their value. For details of subjects and prices see below. 
ANATOMY {Double Number) — By Fred J. 

Brockway, M. D., Assistant Demonstrator of 

Anatomy, College of Physicians and Surgeons, 

New York, and A. O'Malley, M.D., Instructor 

in Surgery, New York Polyclinic. 81.75. 
P H Y S I O L O G Y— By F. A. Manning, M. D., 

Attending Surgeon, Manhattan Hosp.,N.Y. $1. 
CHEMISTRY AND PHYSICS — By Joseph 

Strttthers, Ph. B., Columbia College School of 

Mines, N.Y., and D. W. Ward, Ph. B., Columbia 

College S :hool of Mines, N. Y., and Chas. H. 

Willmarth, M. S., N. Y. Si. 
HISTOLOSY, PATHOLOGY AND BAC- 

TERIOLOCY— By Bennett S. Beach, M D., 

Lecturer on Histology, Pathology aad Bacte- 
riology, New York Polyclinic. SI. 
MATERIA MEDICA AND THERAPEU- 
TICS— By L. F. Waenek, M. D., Attending 

Pnysician, St. Bartholomew's Disp., N. Y. SI. 
PRACTICE OF MEDICINE, INCLUDINC 

NERVOUS DISEASES— By Edwin T. Dou- 

bledat, M.D., Member N.Y. Pathological Soci- 
ety, and J. D. Nagf.l, M. D , Member N. Y. 

County Medical Association. Si. 
SURCERY (Double Number)— By Bern B. Gal- 

laudet, M. D., Visiting Surgeon, Bellevue 

Hospital, N.Y., and Charles Dixon Jones, M. D m 

Surgeon Yorkville Dispensary, N. Y. SL.75. 

For special circular with full information and specimen pages address the publishers 
Lea Brothers & Co., Publishers, 706, 70S & 710 Sansom Street, Philadelphia. 



CENITO - URINARY AND VENEREAL 

DISEASES— By Charles H. Chetwood, M.D., 
Visiting Surgeon, Demi.t Dispensary, Dep. of 
Surg, and Gen.-Urin. Dis., New York. SI. 

DISEASES OF THE SKIN— By Charles C. 
Ransom, M. D., Assistant Dermatologist, Yan- 
deroilt Clinic, New York. SI. 

DISEASES OF THE EYE, EAR, THROAT 

AND NOSE— By Frank E. Miller, M.D., 
Throat Surgeon, Yandertult Clinic, New York, 
James P. McEvoy, M.D., Throat Surgeon, Belle- 
vue Hosp., Out-Patient Dep., New York, and 
J. E Weeks, M D., Lect. on Ophthal. and 
Otol., Believue Hosp., Med. Col., N. Y. Si. 

OBSTETRICS — By Charles W. Hayt, M.D., 
House Pnysician, Nursery and Child's Hospi- 
tal, New Y'ork. §1. 

GYNECOLOGY— By G. W. Bratenahl, M. D., 
Assistant in Gynecology, Yanderbilt Clinic, 
New Y'ork, and Sinclair Tousey, M. 1'., Assist- 
ant Surgeon, Oat-Patient Department, Roose- 
velt Hospital, New Y'ork. SI. 

DISEASES OF CH I LDREN-By C. A. Rhodes, 
M. 1)., Instructor in Diseases of Children, New 
York Pest-Graduate Medical College. SI. 



Dictionaries, 



NEW EDITION. THOROUGHLY REVISED. JUST READY. 

2>ungltson'6 2Hcttonan> 

OF MEDICAL SCIENCE. 

WITH THE 

Pronunciation, Accentuation and Derivation 

OK THE TERMS. 

Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology, 
Medical Chemistry, Pharmacology, Pediatrics, Pharmacy, Therapeutics, Medicine, Hy- 
giene, Dietetics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, 
Obstetrics, Medical Jurisprudence and Dentistry, etc., etc. With the Pronunciation, 
Accentuation and Derivation of the Terms. By Eobley Dunglison, M. D., late Professor 
of Institutes of Medicine in the Jefferson Medical College of Philadelphia. New (21st) 
edition, thoroughly revised and greatly enlarged by Eichaed J. Dtjnglison, A. M., M. D. 
In one very large and handsome royal octavo volume of 1200 pages. Cloth, $7.00; 
leather, raised bands, $8.0 >\ 

THIS great medical dictionary, which has been for more than two generations the 
standard of the English speaking race, is now, after several years of incessant 
labor, issued in a thoroughly revised and greatly enlarged and improved edition. 
The new words and phrases aggregate over 44,000 and by themselves would fill a 
large volume. Space has been gained by the excision of everything obsolete, and the 
page has been much enlarged, so that while the new edition contains far more matter than 
its predecessor, the whole is accommodated within a volume convenient for the hand. 

The revision has not only covered every word, but it has resulted in a number of 
important new features designed to confer on the work the utmost usefulness, and to make 
it answer the most advanced demands of the times. 

Pronunciation has been introduced throughout by means of a simple and obvious 
system of phonetic spelling. At a glance the proper sound of a word is clearly indicated, 
and thus a most important desideratum is supplied. 

Derivation affords the utmost aid in recollecting the meanings of words, and gives 
the power of analyzing and understanding those which are unfamiliar. It is indicated in 
the simplest manner. Greek words are spelled with English letters, and thus placed at 
the command of those unfamiliar with the Greek alphabet. 

Definitions, the essence of a dictionary, are clear and full, a characteristic in 
which this work has always been preeminent. In this edition much explanatory and 
encyclopedic matter has been added, especially upon subjects of practical value. Thus 
under the various diseases will be found their symptoms, treatment, etc. ; under drugs their 
doses and effects, etc., etc. A vast amount of information has been clearly and conveniently 
condensed into tables in the alphabet. 

The typography is thoroughly in keeping with the excellence of the literary material. 
In a word, both the editor and the publishers have felt that the world-wide reputation of 
Dunglison's Dictionary has rendered it incumbent on them to ensure that in its re- 
modelled and enlarged shape it should be found equal to all that the student and practi- 
tioner can expect from such a. work. 

The National Medical Dictionary, 

Including English, French, German, Italian and Latin Technical Terms used in 
Medicine and the Collateral Sciences, and a Series of Tables of Useful Data. By John 
S. Billings, M. D., LL. D., Edin. and Harv., D. C. L., Oxon., member of the National 
Academy of Sciences, Surgeon U. S. A., etc. In two very handsome royal octavo volumes 
containing 1574 pages, with two colored plates. Per volume — cloth, $6.00 : leather, $7.00; 
half morocco, marbled edges, $8.50. For sale by subscription only. Specimen pages 
on application. Address the publishers. 



Its scope is one which will at once satisfy the 
student and meet all the requirements of the med- 
ical practitioner. Clear and comprehensive defi- 
nitions of words should form the prime feature of 
any dictionary, and in this one the chief aim 
seems to be to give the exact signification and the 
different meanings of terms in use in medicine 
and the collateral sciences in language as terse as 
is compatible with lucidity. The work is remark- 
able, too, for its fulness, it presents to the Eng- 
lish reader a thoroughly scientific mode of 
acquiring a rich vocabulary and offers an accurate 
and ready means of reference in consulting works 
in any of the three modern continental languages 



which are richest in medical literature. Apart from 
the boundless stores of information which may be 
gained by the study of a good dictionary, one is 
enabled by the work under notice to read intelli- 
gently any technical treatise in any of the four 
chief modern languages. There cannot be two 
opinions as to the great value and usefulness of 
this dictionary as a book of ready reference for all 
sorts and conditions of medical men. So far as 
we have been able to see, no subject has been 
omitted, and in respect of completeness it will be 
found distinctly superior to any medical lexicon 
yet published. — The London Lancet, April 5, 1890. 



HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used, in Medicine and the 
Collateral Sciences. By Richard D. Hobltn, M. D. In one large royal 12mo. volume of 520 double- 
columned pages. Cloth, $1.50; leather, $2.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy. 



NEW (THIRTEENTH) EDITION. JUST READY. 

GRAY'S ANATOMY 

IN COLORS OR IN BLACK. 



Anatomy, Descriptive and Surgical, 

BY HENRY GRAY, F. R. S., 

LECTURER OX ANATOMY AT ST. GEORGE'S HOSPITAL, LONDON. 

Edited by T. PICKERING PICK, F.Pv. C. S., 

Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, 
Royal College of Surgeons of England. 

A new American from the thirteenth enlarged and improved London edition. In one 

imperial octavo volume of 1100 pages, with 635 large and elaborate engravings 

on wood. Price, with illustrations in colors, cloth, $7 ; leather, $8. 

Price, with illustrations in black, cloth, 86 ; leather, $7. 

SINCE 1S57 Gray's Anatomy has been the standard work used by students of 
medicine and practitioners in all English-speaking races. So preeminent has it 
been aniODg the many works on the subject that thirteen editions have been 
required to meet the' demand. This opportunity for frequent revisions has been 
fully utilized and the work has thus been subjected to the careful scrutiny of many of the 
most distinguished anatomists of a generation, and thus a degree of completeness and ac- 
curacy lias been secured which is not attainable in any other way. In no former revision 
has so much care been exercised as in the present to provide for the student all the 
assistance that a text-book can furnish. The engravings have always formed a distin- 
guishing feature of this work, and in the ]3resent edition the series has been enriched and 
rendered complete by the addition of many new ones. The large scale on which the 
illustrations are drawn and the clearness of the execution render them of unequalled 
value in affording a grasp of the complex ditails of the subject. As heretofore the name 
of each part is printed in the engraving, thus conveying to the eye at once the position, 
extent and relations of each organ, vessel, muscle, bone or nerve with a clearness impos- 
sible when figures or lines of reference are employed. Distinctive colors have been em- 
ployed to give additional prominence to the attachments of muscles, the veins, arteries 
and nerves. For the sake of those who prefer hot to pay the slight increase in cost 
necessitated by the use of colors, the volume is published also in black alone. 

The illustrations thus constitute a complete and splendid series, which will greatly 
assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room. Combining as it does a complete Atlas of Anatomy 
with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers 
a more extended range of subjects than is customary in the ordinary text-books. Jt not 
only answers every need of the student in laying the groundwork of a thorough medical 
education, but owing to its application of anatomical details to the practice of medicine 
and surgery, it also furnishes an admirable work of reference for the active practitioner. 
A few notices of the previous edition are appended : 

Gray's standard Anatomy has been and will be ; The work is published with black and colored 
for years the text-book for students. The book plates. It is a marvel of book-making.— A merican 
needs only to be examined to be perfectly under- i Practitioner and News. 
stood.— Medical Press of Western New York. | Gray's Anatomy is the most magnificent work 

A work which for more than twenty years has upon anatomy which has ever been puhlished in 
had the lead of all other text-books on anatomy. I the English or any other language.— Cincinnati 
It would be indeed difficult to name a feature Medical News. 

wherein "Gray" could be mended or bettered, i The best work on anatomy that is published in 
and it needs no prophet to see that the royal any language.— Virqinia Medical Monthly. 
work is destined for many years to come to hold ' The most popular work on anatomy ever written, 
the first place among anatomical text-books. , — Journal of the American Medical Association. 



Holden's Landmarks, Medical and Surgical. 

Landmarks, Medical and Surgical. By Luther Holden, F. K. C. S., 
Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Second American 
from the third and revised English edition, with additions by W. W. Keen, M. D., Pro- 
fessor of Artistic Anatomy in the Penna. Academy of Fine Arts. In one 12mo. volume 
of 148 pages. Cloth, $1.00. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy, Physiology. 



HUMAN MONSTROSITIES 

BY BARTON C. HIRST, M. D., and GEORGE A. PIERSOL, M. D. 



Professor of Obstetrics in the University 
of Pennsylvania. 



Professor of Anatomy and Embryology 
in the University of Pennsylvania. 



Magnificent folio, containing 220 pages of text, illustrated with engravings, and 
39 full- page, photographic plates from nature. In four parts, price, each, $5. Complete 
'work just ready. Limited edition, for sale by subscription only. Address the Publishers. 



We have before us the fourth and last part of 
the latest and best work on human monstrosi- 
ties. This completes one of the masterpieces of 
American medical literature. Typographically 
and from an artistic standpoint, the work is un- 
exceptionable. In this last ard final volume 



must always retain the honor of being the first of 
its kind written in the English language. — The 
British Medical Journal, May 27, 1893. 

This work promises to be' one for which a place 
must be found in the library of every anatomist, 
pathologist, obstetrician and teratologic. It is the 



is presented the most complete bibliography of joint production of an obstetrician, and an embry- 
teratological literature extant. No library will be i ologist, and histologist, and this fact makes it 
complete without this magnificent work.— Jour- certain that both the obstetric and anatomical 
nal of the American Medical Asso., May 6, 1893. sides of the subject will be fully represented and 
Altogether, Human Monstrosities is a satisfactory I described. The book promises to be one of the 
production. It will take its place as a standard greatest value to the EDglish-speaking medical 
work on teratology in medical libraries, and it | world.— Edinburgh Medical Journal, April, 1892. 



Mien's System of Human Anatomy. 



A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. By Harrison 
Allen, M. D., Professor of Physiology in the University of Pennsylvania. With an 
Introductory Section on Histology by 'E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; 
also bound in one volume, cloth, $23.00 ; very handsome half Russia, raised bands and 
open back, $25.00. For sale by subscription only. Address the Publishers. 



Clarke & Lockwood's Dissector's Manual. 

The Dissector's Manual. By W. B. Clarke, F. R. C. S., and C. B. Lock- 
wood, F. R. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical 
School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. 
Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 
Messrs. Clarke and Lock wood have written a book I intimate association with students could have 

iven. With such a guide as this, accompanied 



that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best way to display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



by so attractive a commentary as Treves' Surgical 
Applied Anatomy (name series), no student could 
fail to be deeply and absorbingly interested in the 
study of anatomy. — New Oi-leans Medical and Sur~ 
gical Journal, April, 1884. 



Treves' Surgical Applied Anatomy. 



Surgical Applied Anatomy. By Frederick Treves, F. E. C. S., Senior 
Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- 
size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, p. 30. 



Bellamy's Surgical Anatomy. 

The Student's Guide to Surgical Anatomy : Being a Description of t ue 
most Important Surgical Kegions of the Human Body, and intended as an Introduction to 
Operative Surgery. By Edward Bellamy, F. B. C. S., Senior Assistant- Surgeon to me 
Charing- Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. 

Wilson's Human Anatomy. 

• A System of Human Anatomy, General and Special. By Erasmus 
Wilson, F. B. S. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical 
Anatomy in the Medical College of Ohio. In one large and handsome octavo volume 
of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
12mo., 310 pages, 220 woodcuts. Cloth, $1.75. 

HORNER'S SPECIAL ANATOMY AND HISTOL- 



OGY. Eighth edition. In two octavo volumes 
of 1007 magfts with 320 woodcuts. Cloth. $6.00. 
CLELA.ND'S DIRECTORY FOR THE DISSEC- 
TION OF THE HUMAN BODY. 12mo., 173 pp. 
Cloth, $1.25. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Physics, Physiology, Anatomy, Chemistry. 



Draper's Medical Physics. 

Medical Physics. A Text-book for Students and Practitioners of Medicine. 
Bv John C. DRAPER, M. D., LL. D., Prof, of Chemistry in the Univ. of the City of 
New York. In one octavo vol. of 734 pages, with l>7i) woodcuts, mostly original. Cloth, $4. 

While all enlightened physicians will agree that No man in America was better fitted than Dr. 
a knowledge of physics is desirable for tho medi- Draper for the task he undertook and he lias pro- 
cal student, only those actually engaged in the vided the student and practitioner of medicine 
teaching of the primary subjects can be fully with a volume at once readable and thorough, 
aware of the difficulties encountered by students -Even to the student who has some knowledge of 
who attempt the study of these subjects without I physics this book is useful, as it shows him its 
a knowledge of either physics or chemistry, applications to the profession that he has chosen. 
These are especially felt by the teacher of physi- Dr. Draper, as an old teacher, knew well the diffi- 
ology. culties to be encountered in bringing his subject 

It "is, however, impossible for him to impart a ! within the grasp of the 'average student, and that 
knowledge of the main facts of his subject and he has succeeded so well proves once more that 
establish them by reasons and experimental dem- | the man to write for and examine students is the 
onstration, and at the same time undertake to one who has taught and is teaching them. The 
teach nb initio the principles of chemistry or phys- j book is well printed and fully illustrated, and in 
ics. Hence the desirability, we may say the every way deserves grateful recognition. — The 
necessity, for some such work as the present one. | Montreal Medical Journal, July, 1890. 



Power's Human Physiology.— Second Edition. 

Human Physiology. By Henry Power, M. B., F, E. C. S., Examiner in 
Physiology, Royal College of Surgeons of England. Second edition. In one 12mo. vol. 
of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 30. 

Robertson's Physiological Physics. 

Physiological Physics. By J. McGregor Robertson, M. A., M. B., 
Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 
537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. 

ments. It will be found of great value to the 



The title of this work sufficiently explains the 
nature of its contents. It is designed as a man- 
ual for the student of medicine, an auxiliary to 
his text-book in physiology, and it would be particu 



practitioner. It is a carefully prepared book of 
reference, concise and accurate, and as such we 
heartily recommend it. — Journal of the American 



larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6. 1884. 



Dalton on the Circulation of the Blood. 

Doctrines of the Circulation of the Blood. A History of Physio- 
logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. 
Dalton, M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- 
geons, New York. In one handsome 12mo. volume of 293 pages. Cloth, $2. 



Dr. Dalton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 



ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 



Bell's Comparative Anatomy and Physiology. 

Comparative Anatomy and Physiology. By F. Jeffrey Bell, M. A., 
Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 
pages, with 229 illustrations. Limp cloth, $2. See Students' Series of Manuals, page 30. 

The manual is preeminently a student's book — I it the best work in existence in the English 
clear and simple in language and arrangement, j language to place in the hands of the medical 
It is well and abundantly illustrated, and is read- student. — Bristol Medico-Chirurgical Journal, Mar. 
able and interesting. On the whole we consider 1886. 



Ellis' Demonstrations of Anatomy.— Eighth Edition. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy 
in University College, London. From the eighth and revised London edition. In one 
very handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25 ; leather, $5.25. 

Roberts' Compend of Anatomy. 

The Compend of Anatomy. For use in the dissecting-room and in pre- 
paring for examinations. By John B. Roberts, A.M., M. D., Lecturer in Anatomy in 
the University of Pennsylvania. In one 16mo. vol. of 196 pages. Limp cloth, 75 cents. 



WOHLER'S OUTLINES OF ORGANIC CHEM- 
ISTRY. Edited by Fittig. Translated by Ira 
Remsen, M. D , Ph. D. In one 12mo. volume of 
550 pages. Cloth, $3. 

LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 



CARPENTER'S HUMAN PHYSIOLOGY. Edited 
bv Henry Power. In one octavo volume. 

CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



8 



Physiology— (Continued), Chemistry. 



Foster's Physiology.— Fifth Edition. 

Text-Book of Physiology. By Michael Foster, M. D., F. E. S., Prelec- 
tor in Physiology and Fellow of Trinity College, Cambridge, England. New (fourth) and 
enlarged American from the fifth and revised English edition, with notes and additions* 
In one handsome octavo vol. of 1072 pages, with 282 illus. Cloth, $4.50; leather, $5.50. 
The appearance of another edition of Foster's the author largely adopted in a modified form in 
Physiology again reminds us of the continued 
popularity of this most excellent work. There 
can be no doubt that this text-book not only con- 
tinues to lead all others in the English language 



this revision, much was still left to be done by the 

editor to render the work fully adapted to the wants 

of our American students, so that the American 

, edition will undoubtedly continue to supply the 

but that this last edition is superior to its prede- market on this side of the Atlantic. The work 



cessors. It is evident that the author has devoted 
a considerable amount of time and labor to its 
preparation, nearly every page bearing evidences 
of careful revision. Although the work of the 
American editor in former editions has been by 



has been published in the characteristic creditable 
style of the Lea's, and owing to its enormous sale, 
is offered at an extremely low price.— The Medical 
and Surgical Reporter, Jan. 9, 1892. 



Dalton's Physiology.— Seventh Edition. 

A Treatise on Human Physiology. Designed for the use of Students 
and Practitioners of Medicine. By John C. Dalton, M. D., Professor of Physiology in 
the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly 
revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- 
tiful engravings on wood. Cloth, $5.00 ; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth.— N. 7. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
oneVhich we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



Chapman's Human Physiology. 



A Treatise on Human Physiology. By Henry C. Chapman, M. D., 
Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia* 
In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50 ; leather, $6.50. 

nical matters are given in minute detail; elabo- 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 18S7. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 



rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no- 
farther, and the latter will find entertainment and 
instruction in an admirable book of reference. — 
North Carolina Medical Journal, Nov. 1887. 



Schofield's Elementary Physiology— Just Ready. 

Elementary Physiology for Students. By Alfred T. Schofield, 
M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 
227 engravings and 2 colored plates containing 30 figures. Cloth, §2.00. 

Frankland & Japp's Inorganic Chemistry. 

Inorganic Chemistry. By E. Frankland, D. C. L., F. E. S., Professor of 
Chemistry in the Normal School of Science, London., and F. R. Japp, F. I. C, Assistant 
Professor of Chemistry in the Normal School of Science, London. In one handsome 
octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 



This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry,with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 



chemical knowledge is behind the times, would 
do well to study this work. The descriptions and 
demonstrations are made so plain that there is- 
no difficulty in understanding them. — Cincinnati 
Medical News, January, 1886. 



Clowes' Qualitative Analysis.— Third Edition. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. By Frank Clowes, D. Sc, London, Senior Science-Master 
at the High School, Newcastle-under-Lyme, etc. Third American from the fourth and 
revised English edition. In one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. 

CLASSEN'S ELEMENTARY QUANTITATIVE I fessor of Chemistry in the Towne Scientific School,. 
ANALYSIS. Translated, with notes and addi- University of Penna. In one 12mo. volume of 324 
tions, by Edgak F. Smith, Ph. D., Assistant Pro- | pages, with 36 illus. Cloth, $2.00. 



Lea Brothers & Co.. Publishers, 70S, 708 &710 Sansom Street, Philadelphia. 



Chemistry — (Continued). 



Simon's Chemistry.— New (4th) Edition. Just Ready. 

Manual Of Chemistry. A Guide to Lectures and Laboratory work for Begin- 
ners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medi- 
cine. By W. Simon, Ph. P., M. IX, Professor of Chemistry and Toxicology in the College 
of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- 
lege of Pharmacy. New (4th) edition. In one 8vo. vol. of 490 pp., with 44 woodcuts and 
7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25. 



A work which rapidly passes to its fourth edition 
needs no further proof of having achieved a buo- 
oesa In the present case the claims to favor are 
obvious. Emanating from an experienced teacher 
of medical and pharmaceutical students the vol- 
ume is closely adapted to their needs. This is 
shown not only by the careful selection and clear 
presentation of its subject matter, but by the 
colored plates of reactions, which form a unique 
feature. Every teacher will appreciate the saving 
of his own time, and the advantages accruing to 
the student from a permanent and accurate stan- 



dard of comparison for tests depending on colors, 
and frequently upon their changes. To the prac- 
titioner, who is likely to be confronted at any time 
with important pathological or toxicological ques- 
tions to be answered by the test tube, the volume 
will be of the utmost value. Such it has proved 
in the past, and the author has accordingly been 
enabled, through frequent and thorough revisions 
to keep his work constantly in touch with trie 
progress of its science and the best methods of its 
presentation.— Kansas City Medical Index, May, 
1893. 



Fownes' Chemistry.— Twelfth Edition. 

A Manual of Elementary Chemistry; Theoretical and Practical. By 
George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New 
American, from the twelfth English edition. In one large royal 12mo. volume of 1061 
pages, with 168 engravings and a colored plate. Cloth, $2.75 ; leather, $3.25. 

Fownes' Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fulty known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 



cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 
chemistry extant. — Cincinnati Med. News, Oct. '85. 



Attfield's Chemistry.— Twelfth Edition. 

Chemistry, General, Medical and Pharmaceutical; Including the 
Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the 
Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., 
Ph.D., F. I.C., F. R. S., etc., Professor of Practical Chemistry to the Pharmaceutical 
Society of Great Britain, etc. A new American, from the twelfth English edition, 
specially revised by the Author for America. In one handsome royal 12mo. volume of 
782 pages, with 88 illustrations. Cloth, $2.75 ; leather, $3.25. 

mass of well-arranged information that it will al- 
ways serve as a handy book of reference. He 
does not allow any unutilizable knowledge to slip 
into his book; his long years of experience have 
produced a work which is both scientific and 
practical, and which shuts out everything in the 
nature of a superfluity, and therein lies the secret 
of its success. This last edition shows the marks 
of the latest progress made in chemistry and chem- 
ical teaching.— New Orleans Medical and Surgical 
Journal, Nov. 1889. 



Attfield's Chemistry is the most popular book 
among students of medicine and pharmacy. This 
popularity rests upon real merits. Attfield's work 
combines in the happiest manner a clear exposi- 
tion of the theory of chemistry with the practical 
application of this knowledge to the everyday 
dealings of the physician and pharmacist. His 
book is precisely what the title claims for it. The 
admirable arrangement of the text enables a 
reader to get a good idea of chemistry without 
the aid of experiments, and again it is a good 
laboratory guide, and finally it contains such a 



Bloxam's Chemistry.— Fifth Edition. 

Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professor 
of Chemistry in King's College, London. .New American from the fifth London 
edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 



complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 
the best manuals of general chemistry in the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 



Luff's Manual of Chemistry.— Just Ready. 

A Manual of Chemistry. For the use of students of medicine. By Arthur 
P. Luff, M. D., B. Sc, Lecturer on Medical Jurisprudence and Toxicological Chemistry, 
St. Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 
engravings. Cloth, $2.00. See Students 1 Series of Manuals, page 30. 

Greene's Medical Chemistry. 

A Manual of Medical Chemistry. For the use of Students. By William 
H. Greene, M. D., Demonstrator of Chemistry in the Medical Department of the Uni- 
versity of Pennsylvania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



10 Chemistry — (Continued), Pharmacy. 

Vaughan & Novy on Ptomaines and Leucomaines — 2d Edition. 

Ptomaines, Leucomaines and Bacterial Proteids ; or the Chemi- 
cal Factors in the Causation of Disease. By Victor C. Yaughan, Ph. D., 
M. D., Professor of Physiological and Pathological Chemistry, and Associate Professor of 
Therapeutics and Materia Medica in the University of Michigan, and Frederick G. 
Novy, M. D., Instructor in Hygiene and Physiological Chemistry in Ihe University of 
Michigan. New (second) edition. In one handsome 12mo. vol. of 389 pages. Cloth, $2.25. 



This book is one that is of the greatest import- 
ance, and the modern physician who accepts 
bacterial pathology cannot hare a complete 
knowledge of this subject unless he has carefully 
perused it. To the toxicologist the subject is 
alike of great import, as well as to the hygienist 



and sanitarian. It contains information which 
is not easily obtained elsewhere, and which is 
of a kind that no medical thinker should be 
without. — The American Journal of the Medical 
Sciences, April, 1892. 



Remsen's Theoretical Chemistry.— New (4th) Edition. 

Principles of Theoretical Chemistry, with special reference to the Con- 
stitution of Chemical Compounds. By Ira Kemsen, M. D., Ph. D., Professor of Chem- 
istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- 
tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. 

The fourth edition of Professor Remsen's well- j lation into German and Italian speaks for its ex- 
known book comes again, enlarged and revised. ' alted position and the esteem in which it is held 
Each edition has enhanced its value. "We may say by the most prominent chemists. We claim for 
without hesitation that it is a standard work on this little work a leading place in the chemical 
the theory of chemistry, not excelled and scarcely literature of this country. — The American Journal 
equalled by any other in any language. Its trans- | of the Medical Sciences, July, 1893. 



Charles' Physiological and Pathological Chemistry. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. By T. Ckanstotjn 
Charles, M. D., F. B-. S., M. S., formerly Assistant Professor and Demonstrator of Chem- 
istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume 
of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the impor- [ nowadays. Dr. Charles has devoted much space 
tance and practical reach of his subject, and he , to the elucidation ot urinary mysteries. He does 
has treated it in a competent and instructive man- J this with much detail, and yet in a practical and 
ner. We cannot recommend a better book than j intelligible manner. In fact, the author has filled 
the present. In fact, it fills a gap in medical text- [ his book with many practical hints.— Medical Rec~ 
books, and that is a thing which can rarely be said ; ord, December 20, 1884. 



Hoffmann and Powers' Medicinal Analysis. 

A Manual of Chemical Analysis, as applied to the Examination of Medi- 
cinal Chemicals and their Preparations. Being a Guide for the Determination of their 
Identity and Quality, and for the Detection of Impurities and Adulterations. For the 
use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- 
tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to 
the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- 
istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and 
much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

Parrish's Pharmacy.— Fifth Edition. 

A Treatise on Pharmacy : Designed as a Text-book for the Student, and as 
a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
By Edward Parrish, late Professor of the Theory and Practice of Pharmacy in the 
Philadelphia College of Pharmacy. Fifth edition, thoroughly revised, by Thomas S. 
"Wlegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. 
Cloth, $5.00 ; leather, $6.00. 

No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to 
himself of so useful a guide to practice, and no leave this work out of the list of their works of 
physician who properly estimates the value of an j reference. The country practitioner, who must 
accurate knowledge of the remedial agents em- j always be in a measure his own pharmacist, will 
ployed by him in daily practice, so far as their find it indispensable. — Louisville Medical News, 
miscibility, compatibility and most effective meth- March 29, 1884. 



Ralfe's Clinical Chemistry. 

Clinical Chemistry. By Charles H. Kalfe, M. D., F. B. C. P., Assistant 
Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, 
with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



flateria Hedica, Therapeutics. 



11 



Stille & Maisch's National Dispensatory.— New (5th) Edition. 

The National Dispensatory. 

Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- 
cines, including those recognized in the Pharmacopoeias of the United States, Great 
Britain and Germany, with numerous references to the French Codex. By Alfred 
Stille, M. D., LL.D., Professor Emeritus of the Theory and Practice of Medicine and of 
Clinical Medicine in the University of Pennsylvania, and John M. Maisch, Phar. D., 
Profesior of Materia Medica and Botany in Philadelphia College of Pharmacy, Secre- 
tary to the American Pharmaceutical Association. New (fifth) edition, revised, and cover- 
ing the new U. S. Pharmacopoeia. In one magnificent imperial octavo volume of about 
1750 pages, with about 325 elaborate engravings. Preparing. 

A FEW NOTICES OF THE PREVIOUS EDITION ARE APPENDED. 



The matters with which it deals are of so prac- 
tical a nature that neither the physician nor the 
pharmaceutist can do without the latest texi-books 
on them, especially those that are so accurate and 
comprehensive as this one. The book is in every 
way creditable both to the authors and to the pub- 
lishers.— The Neio York Medical Journal, May 21, 
1887. 

The authors and publishers have reason to feel 
proud of this, the most comprehensive, elaborate 
and accurate work of the kind ever printed in this 



country. It is no wonder that it has become the 
standard authority for both the medical and phar- 
maceutical profession, and that four editions have 
been required to supply the constant and increas- 
ing demand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 
discovery have received due attention.— Kansas 
City Medical Index, Nov. 1887. 



Maisch's Materia Medica.— New (5th) Edition. 

A Manual of Organic Materia Medica ; Being a Guide to Materia Medica 
of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists 
and Physicians. By John M. Maisch, Phar. D., Prof, of Materia Medica and Botany in 
the Philadelphia College of Pharmacy. New (fifth) edition, thoroughly revised. In one 
very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00. 

point, even for the most severe critic. The book 
fully sustains the wide and well-earned reputa- 
tion of its popular author. In the special line of 
work of which it treats it is fully up to the most 
recent observations and investigations. After a 



This is an excellent manual of organic materia 
medica, as are all the works that emanate from the 
skilful pen of such a successful teacher as John 
M. Maisch. The oook speaks for itself in the most 
forcible language. In the edition before us which 
is the fifth one published within the comparatively 
short space of eight years (and this is the best 
proof of the great value of the work and the 
just favor with which it has been received and 
accepted), the original contents have been thor- 
oughly revised and mucn good and new matter 
has been incorporated. We have nothing but praise 
for Professor Maisch's work. It presents no weak 



careful perusal of the book, we do not hesitate to 
recommend Maisch's Manual of Organic Materia 
Medica as one of the best, if not the best work on 
the subject thus far published. Its usefulness 
cannot well be dispensed with, and students, drug- 
gists, pharmacists and physicians should all pos- 
sess a copy of such a valuable book.— Medical 
News, December 31, 1892. 



Edes' Therapeutics and Materia Medica. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. By Bobert T. Edes, M. D., Jackson Professor of 
Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50 ; leather, $4.50. 
It possesses all the essentials which we expect 



po: 
in a book of its kind, such as conciseness, clear- 
ness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated of. The clinical- index at 
the end will be found very useful. We heartily 
commend the book and congratulate the author 



on having produced so good a one.— N. Y. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action.— Pharmaceutical Era, Jan. 1888. 



Brace's Materia Medica and Therapeutics.— Fourth Edition. 

Materia Medica and Therapeutics. An Introduction to Kational Treat- 
ment. By J. Mitchell Bruce, M. D., F. B. C. P., Physician and Lecturer on Materia 
Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 
12mo. volume of 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 30. 

part of the book contains an outline of general 
therapeutics, each of the symptoms of the body 



The pharmacology and therapeutics of each drug 
are given with great fulness, and the indications for 
its rational employment in the practical treatment 
of disease are pointed out. The Materia Medica 
proper contains all that is necessary for a medical 
student to know at the present day. The third 



being taken in turn, and the methods of treat- 
ment illustrated. A lengthy notice of a book so well 
known is unnecessary. — Med. Chronicle, May, 1S91. 



HERMANN'S EXPERIMENTAL PHARMACOL- I ST I LLE'S THERAPEUTICS AND MATERIA 



OGY. A Handbook of Methods for Determining 
the Physiological Action of Drugs. Translated, 
with the Author's permission, and with exten- 
sive additions, by R. M. Smith, M. D. 12mo., 
199 pages, with 32 illustrations. Cloth, $1.50. 



MEDICA. A Systematic Treatise on the Action 
and Uses of Medicinal Agents, including their 
Description and History. Fourth edition, re- 
vised and enlarged. In two octavo volumes, con- 
taining 193G pages. Cloth, $10.00 ; leather, §12.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



12 Therapeutics, flateria fledica — (Continued). 

A System of Practical Therapeutics 

BY AflERICAN AND FOREIGN AUTHORS. 



Edited by HOBART AHORY HARE, fl. D. 

Professor of Therapeutics and Materia Mediea in the Jefferson Medical College of Philadelphia. 

In a series of contributions by seventy-eight eminent authorities. In three large 
octavo volumes of 3544 pages, with 434 illustrations. Price, per volume: Cloth, $5.00 <; 
leather, $6.00; half Bussia, $7.00. For sale by subscription only. Address the Publishers. 
Full prospectus free to any address on application. 



The various divisions have been elaborated by 
men selected in view of their special fitness. In 
every case there is to be found a clear and concise 
description of the disease under consideration, 
corresponding with the most recent and well- 
established views of the subject, embracing appo- 
site pictorial illustrations where these are neces- 
sary. In treating of the employment of remedies 
and therapeutical measures, the writers have 
been singularly happy in giving in a definite way 
the exact methods employed and the results ob- 
tained, both by themselves and others, so that one 
might venture with confidence to use remedies 
with which he was previously entirely unfamiliar. 
The practitioner could hardly desire a book on 
practical therapeutics which he could consult with 
more interest and profit. — The North American 
Practitioner, September, 1892. 

The scope of this work is beyond that of any 
previous one on the subject. The goal, after all, 



is the treatment of disease, and a work which con- 
tributes to its successful management is to be 
looked upon as of vast use to humanity. It can- 
not be denied that therapeutic resources, whether 
the treatment be confined to the mere administra- 
tion of drugs, or allowed its more extended appli- 
cation to the management of disease, have so 
greatly multiplied within the last few years as to 
render previous treatises of little value. Herein 
will be found the great value of Hare's encyclo- 
pedic work, which groups together within a single 
series of volumes the most modern methods 
known in the management of disease, and espe- 
cially deals with important subjects comprehen- 
sively, which could not be done in a more limited 
treatise. We cannot commend Hare's System 
of Practical Therapeutics too highly; it stands 
out first and foremost as a work to be consulted 
by authors, teachers, and physicians, throughout 
the world. — Buffalo Med. and burg. Jour., Aug. 1892. 



Hare's Text-Book of Practical Therapeutics.— New (3d) Ed. 

A Text-Book of Practical Therapeutics ; With Especial Keference to 
the Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Mediea 
in the Jefferson Medical College of Philadelphia ; Sec. of Convention for Revision of U. S. 
Pharmacopoeia of 1890. With special chapters by Drs. G. E. de Schweinitz, Edward 
Martin, J. Howard Reeves and Barton C. Hirst. New (3d) and revised edition. 
In one octavo volume of 689 pages. Cloth, $3.75 ; leather, $4.75. Just Heady. 

directions for the most approved treatment. The 



We find here directions for the use of the drugs 
of the most recent introduction, and the very lat- 
est results obtained in the treatment of disease by 
these newer remedies. There is also a list of 
drugs arranged according to their physiological 
action, and a list of definitions of the terms used to 
designate classes of drugs. In a word, this book 
is a treatise on drugs and other remedial 
measures, with especial reference to their practi- 
cal uses ; and also a treatise on diseases, with full 



book closes with a table of doses and an index of 
diseases and remedies. There are some books 
that the student and practitioner alike would do 
well to purchase; there are others they must 
have. To this latter class belong the text-books 
on practical therapeutics. Certainly none can be 
found either more practical or more complete than 
this. — The National Medical Review, February 2, 
1893. 



Brunton's Therapeutics and Materia Mediea.— Third Ed. 

A Text-Book of Pharmacology, Therapeutics and Materia 
Mediea; By T. Lauder Brunton, M. D., D.Sc, F.R.S., F.E.C.P., Lecturer on 
Materia Mediea and Therapeutics at St. Bartholomew's Hospital, London, etc. Including 
the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Adapted to the U. S. Pharmacopoeia by Francis H. Williams^ M. D., of Harvard Univ 
Med. School. Third edition. Octavo, 1305 pages, 230 illus. Leather, $6.50. 

made in various directions in the art of therapeu- 



No words of praise are needed for this work, for 
it has already spoken for itself in former editions. 
It was by unanimous consent placed among the 
foremost books on the subject ever published in 
any language, and the better it is known and studied 
the more highly it is appreciated. The present 
edition contains much new matter, the insertion 
of which has been necessitated by the advances 



tics, and it now stands unrivalled in its thoroughly 
scientific presentation of the modes of drug action. 
No one who wishes to be fully up to the times in 
this science can afford to neglect the study of Dr. 
Brunton's work. The indexes are excellent, and 
add not a little to the practical value of the book. 
—Medical Record, May 25, 1889. 



Farquharson's Therapeutics and Materia Mediea.— 4th Ed. 

A Guide to Therapeutics and Materia Mediea. By Kobert Far- 
quharson, M. D., F. E. C. P., LL. D., Lecturer on Materia Mediea at St. Mary's Hospi- 
tal Medical School, London. Fourth American, from the fourth English edition. 
Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- 
fessor of Materia Mediea and Therapeutics and Clinical Medicine in the Medico-Chi- 
rurgical College of Philadelphia. In one handsome 12mo. vol. of 581 pp. Cloth, $2.50. 

copoeias, as well as considering all non-official but 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a place in the British and United States Pharma- 



important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal, June, 1889. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine. 



13 



Flint's Practice of Medicine.— Sixth Edition. 

A Treatise on the Principles and Practice of Medicine. Designed 
for the use of Students and Practitioners of Medicine. By Aistin I'i.ixt, M. D., LL. D., 
Professor of the Principles and Practice of Medicine, and of Clinical Medicine in Belle- 
vue Hospital Medical College, N. Y. Sixth edition, thoroughly revised and rewritten 
by the Author, assisted by William H. Welch, M. D., Professor of Pathology, 
Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., Professor 
of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome octavo 
volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50. 

No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 



vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 



in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art. — Cincinnati Medical News, Oct. 1886. 



Bristowe's Practice of Medicine.— Seventh Edition. 

A Treatise on the Science and Practice of Medicine. By John 
Syer Bristowe, M. D., LL. D., F. E. S., Senior Physician to and Lecturer on Medicine 
at St. Thomas' Hospital, London. Seventh edition. In one large octavo volume of 1325 
pages. Cloth, §6.50 ; leather, $7.50. 



Hartshorne's Essentials of Practice.— Fifth Edition. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. By Henry Hartshorne, M. D., LL. D., lately Professor 
of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and 
rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75 ; half leather, $3. 

a better average of actual practical treatment than 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen.— Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 



this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mc. The numerous illustrations will be 
very useful to students especially. These essen- 
tials are most valuable in affording the means to 
see at a glance the whole literature of any disease, 
and the most valuable treatment.— Chicago Medical 
Journal and Examiner, April, 1882. 



Reynolds' System of Medicine. 

A System of Medicine. By J. Kussell Eeynolds, M. D., Professor of the 
Principles and Practice of Medicine in University College, London. With notes and 
additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the Uni- 
versity of Pennsylvania. In three large and handsome octavo volumes, containing 3056 
double-columned pages, with 317 illustrations. Price per volume, cloth, $5.00; sheep, 
$6.00; half Kussia, raised bands, $6.50. Per set, cloth, $15.00; leather, $18.00; half 
Russia, $19.50. Sold only by subscription. 



Cohen's Applied Therapeutics. 



A Handbook of Applied Therapeutics. Being a Study of Principles 
Applicable and an Exposition of Methods Employed in the Management of the Sick. 
By Solomon Solts Cohen, M. D m Professor of Clinical Medicine and Applied Thera- 
peutics in the Philadelphia Polyclinic. In one large 12mo. vol., with illus. Preparing. 



WATSON'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF PHYSIC. From the fifth 
English edition. Edited with additions, and 190 
illustrations, by Hfnry Hartshorne, A.M., M. D., 
late Professor of Hygiene in the University of 
Pennsylvania. In two large octavo volumes of 
1840 pages. Cloth, $9.00; leather, $11.00. 

FLINT ON PHTHISIS: ITS MORBID ANAT- 
OMY, ETIOLOGY, SYMPTOMATIC EVENTS 
AND COMPLICATIONS, FATALITY AND 
PROGNOSIS, TREATMENT AND PHYSICAL 
DIAGNOSIS; in a series of Clinical Studies. In 
one octavo volume of 442 pages. Cloth, $3.50. 

FLINT'S PRACTICAL TREATISE ON THE 
DIAGNOSIS, PATHOLOGY AND TREATMENT 



OF DISEASES OF THE HEART. Second re- 
vised and enlarged edition. In one octavo vol- 
ume of 550 pages, with a plate. Cloth, $4. 

FLINT'S ESSAYS ON CONSERVATIVE MEDI- 
CINE AND KINDRED TOPICS. In one very 
handsome royal 12mo. volume of 210 pages. 
Cloth, $1.38. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K. C . O. Inone8vo. vol. of 354 pp. Cloth, $2.25. 

LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 

LA ROCHE ON YELLOW FEVER, in its Histori- 
cal, Pathological, Etiological and Therapeutical 
Relations. Two octavo vols., 1468 pp. Cloth, $7.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



14 Prac. of fledicine, Treatment, Digestive Syst. 
Lyman's Practice of Medicine. 

The Principles and Practice of Medicine. For the Use of Medical 
Students and Practitioners. By Henry M. Lyman, M. D., Professor of the Principles 
and Practice of Medicine, Bush Medical College, Chicago. In one very handsome octavo 
volume of 925 pages, with 170 illustrations. Cloth, $4.75 ; leather, $5.75. 



This is an excellent treatise on the practice of 
medicine, written by one who is not only familiar 
with his subject, but who has also learned through 
practical experience in teaching, what are the 
needs of the student, and how to present the facts 
to his mind in the most readily assimilable form. 
Although the book contains over nine hundred 
pages, there has been no space wasted by useless 
historical essays, prolonged discussions on de- 
batable topics, or "padding" of any kind. Each 
subject is taken up in order, treated clearly but 
briefly, and dismissed when all has been said that 
need be said in order to give the reader a clean- 
cut picture of the disease under discussion. The 
reader is not confused by having presented to him 
a variety of different methods of treatment, among 
which he is left to choose the one most easy of exe- 
cution, but the author describes the one which is, 
in his judgment, the best. This is as it should be. 



What the student should be taught is the one 
most approved method of treatment. We have 
spoken of the work as one for the student, and 
this because the author occupies so prominent a 
position as a teacher, but we would not be under- 
stood that it is adapted only for students. There 
is many a practitioner of ten years' or more stand- 
ing, who has been unable to follow the constant 
advances made in medical science, to whom this 
work will be of great use. He will find here each 
subject presented in its latest aspect, and only 
such theories mentioned as have been generally 
accepted by the highest authorities. The practi- 
cal and busy man who wants to ascertain in a 
short time all the necessary facts concerning the 
pathology or treatment of any disease, will find 
here a safe and convenient guide. — Medical Rec- 
ord, October 22, 1892. 



The Year-Book of Treatment for 1893. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine and Surgery, in one 12mo. vol. of 501 pages. Cloth, $1.50. 

*** For special commutations with periodicals see pages 1 and 2. 



The Year-Book of Treatment for 1893 easily 
holds Its advanced place among the many annuals 
and abstracts forming so marked a feature of 
modern medical literature. Its pages give a criti- 
cal and well-arranged review of tne best that the 
year has brought forth in all departments of ther- 



apeutics. Among so much that is excellent one 
can scarcely choose. Commendable features are 
the Summary of Therapeutics and the Selected 
List of New Books. There is as usual a good 
index. — The Medical News, May 20, 1893. 



The Year-Books of Treatment for 1891 and 1892. 

12mos., 485 pages. Cloth, $1.50 each. 

The Tear-Books of Treatment for 1886 and 1887. 

Similar to above. 12mo., 320-341 pages. Cloth, $1.25 each. 
For Sale by Subscription Only. 

A System of Practical Medicine. 

BY AMERICAN A TJTHORS. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. 

* * The greatest distinctively American work on I 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 



lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome of 
American brains, and is marked throughout by 
much of the sturdy independence of thought and 
originality that is a national characteristic. Yet no- 
where is there lack of study of the most advanced 
views of the day.— N. C. Med. Jour., Sept. 1886. 



Habershon on the Abdomen. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. By 
S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- 
tice of Medicine at Guy's Hospital, London. Second American from third enlarged and 
revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. 



This valuable treatise on diseases of the stomach 
and abdomen will be found a cyclopsedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 



rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
—New York Medical Journal, April, 1879. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine, Diagnosis, Heart. 15 



Whitla's Dictionary of Treatment. 

A Dictionary of Treatment ; or Therapeutic Index, including 
Medical and Surgical Therapeutics. By William \\ ihtla, Ml D., Professor 
of Materia Medica and Therapeutics in the Queen's College, Belfast. Revised and adapted 
to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00. 



Dr. Whitla has, we think, been fortunate in the 
selection of a title for his latest work. We have 
already dictionaries of medicine and dictionaries 
of surgery; he now provides us with a dictionary 
of treatment. And reference to the volume shows 
that it really is what it professes to be. The sev- 
eral diseased conditions are arranged in alphabet- 
ical order, and the methods— medical, surgical, 
dietetic, and climatic— by which they may be met, 
considered. On every page we find clear and de- 
tailed directions for treatment supported by the 
author's personal authority and experience, whilst 
the recommendations of other competent observers 
are also critically examined. The book abounds 
with useful, practical hints and suggestions, and 
the younger practitioner will find in it exactly the 
help he so often needs in the treatment botn of 
those who are ill, and those who are ailing. At the 
same time the most experienced members of the 
profession may usefully consult its pages for the 
purpose of learning what is really trusTworthy in 
the later therapeutic developments. The Diction- 
ary is, in short, the recorded experience of a prac- 



tical scientific therapeutist, who has carefully 
studied diseases and disorders at the bed-side and 
in the consulting-room, and has earnestly ad- 
dressed himself to the cure and relief of his 
patients. Dr. Whitla is to be congratulated upon 
the thoroughness with which he has realized his 
idea.— The Glasgow Medical Journal, April, 1892. 

This is a book for the busy general practitioner. 
It is more than a therapeutic index presenting as 
it does clinical therapeutics in its broadest aspect. 
The names of diseases and of prominent condi- 
tions and symptoms are arranged alphabetically, 
while under each title is presented a concise yet 
thorough consideration of the best and generally 
accepted methods of treatment, precedence gen- 
erally being given to those the efficacy of which 
has been demonstrated in the experience of the 
author. No department of medicine has been 
ignored. An index of nineteen pages gives com- 
pleteness to the work, and renders reference easy. 
This book will be of great assistance to the medi- 
cal practitioner. — The Medical News, April 16, 1892. 



Fothergill's Handbook of Treatment.— Third Edition. 

The Practitioner's Handbook of Treatment ; Or, The Principles of 
Therapeutics. By J. Miexee Fothergell, M. D., Edin., M. K. C. P., Lond., Physician 
to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. 
volume of 661 pages. Cloth, $3.75 ; leather, $4.75. 

This is a wonderful book. If there be such a physicians. The practical value of the volume is 
thing as "medicine made easy," this is the work to greatly increased by the introduction of many 



accomplish this result.— Fa. Med, Month., June,'87. 
To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 
a great convenience to many thoughtful but busy 



prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition. — N. Y. Med. Jour., June 11,'87. 
We do not know a more readable, practical and 
useful work on the treatment of disease. — Pacific 
Medical and Surgical Journal, October, 1887. 



Flint on Auscultation and Percussion.— Fifth Edition. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis 
of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austen - Feest, M. D., 
LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- 
cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer 
on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- 
some royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75. 
This little book through its various editions has oughness of Prof. Flint's investigations. For stu- 



probably done more to advance the science of 
physical exploration of the chest than any other 
dissertation upon the subject, and now in its fifth 
edition it is as near perfect as it can be. The 
rapidity with which previous editions were sold 
shows how the profession appreciated the thor- 



dents it is excellent. Its value is shown both in 
the arrangement of the material and in the clear, 
concise style of expression. For the practitioner 
it is a ready manual for reference.— ISorth Ameri- 
can Practitioner, January, 1891. 



Musser's Medical Diagnosis.— Preparing. 

A Practical Treatise on Medical Diagnosis. For the Use of Students 
and Practitioners. By John H. Mussee, M. D., Assistant Professor of Clinical Medicine, 
University of Pennsylvania, Philadelphia. In one octavo vol. of about 650 pp. Preparing. 

Broadbent on the Pulse. 

The Pulse. By W. H. Broadbent, M. D., F. E. C. P., Physician to and Lecturer 
on Medicine at St. Mary's Hospital, London. In one 12mo. volume of 312 pages. 
Cloth, $1.75. See Series of Clinical Manuals, page 30. 



TANNER'S MANUAL OF CLINICAL MEDICINE 
AND PHYSICAL DIAGNOSIS. Third American 
from the second London edition. Revised and 
enlarged by Tilbury Fox, M. D. In one 12mo. 
volume of 3G2 pp. with illus. Cloth, Sl.50. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Frank H. Davis, M.D. Second 
edition. 12mo. 287 pages. Cloth, 81.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pa«es. Cloth. 82.50. 

FLINT'S PRACTICAL TREATISE ON THE 
PHYSICAL EXPLORATION OF THE CHEST 



AND THE DIAGNOSIS OF DISEASES AF- 
FECTING THE RESPIRATORY ORGANS. 
Second and revised edition. In one handsome 
octavo volume of 591 pages. Cloth, S-1.50. 

STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, 81.25. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, 83.00. 

HOLLAND'S MEDICAL NOTES AND REFLEO 
TIONS. 1 vol. 8vo M pp. 493. Cloth, 83.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



16 Practice, Electricity, Cholera, Food, Hygiene. 
Bartholow on Electricity in Medicine and Surgery.— 3d Ed. 

Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. By Eobekts Bartholow, A. M., M. D., LL. D., Emeritus Pro- 
fessor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila- 
delphia, etc. Third edition. In one octavo volume of 308 pp., with 110 illus. Cloth, $2.50. 

Professor Bartholow's practical treatise on the 
application of electricity to medicine and surgery, 
having reached a third edition, scarcely requires 
detailed notice. Originally intended for students 



and practitioners, it starts by assuming an " entire 
unacquaintance with the elements of the subject." 
The work appears to be fitted by its extreme 
lucidity for the use of busy practitioners who re- 
quire a guide in practical electro-therapeutics. — 
London Lancet, January 14, 1888. 
The fact that this work has reached its third edi- 



tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity, demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
The matter added to the present edition embraces 
the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner. — The Medical News, May 14, 1887. 



Bartholow on Cholera.— Just Ready. 

Cholera : Its Causes, Symptoms, Pathology and Treatment. By 

Roberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General 
Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. 
volume of 127 pages, with 9 illustrations. Cloth, $1.25. 

The most scientific work on cholera extant. | pathology of the disease are described separ- 
Broad yet comprehensive, concise but explicit, it ately in a brief and comprehensive manner. The 
treats the subject in a way to invite bat little criti- I final chapter, on the treatment of cholera, gives 
cism. The most valuable chapter is the one on j the prophylactic measures, including quarantine 
treatment, which, considering the author's thera- and the latest therapeutical methods in vogue in 
peutical experience, and the great improvement | India, Europe and America The volume is writ- 
made in practice, is indeed, a contribution to ; ten in the author's usual pleasant style, and will 
medical literature worthy of more than passing satisfy the desire of any one that wishes to obtain 
notice — The Medical Fortnightly, July 15. 1893. i the most recent information on the subject. — The 

The author has sought to make a practical book \ New York Medical Journal, July 29, 1893. 
in the smallest compass. The symptoms and J 



Yeo on Food in Health and Disease. 

Food in Health and Disease. By I. Burxey Yeo, M.D., F.E.C.P., 
Professor of Clinical Therapeutics in King's College, London. In one 12mo. volume of 
590 pages. Cloth, $2.00. See Series of Clinical Manuals, page 30. 



Dr. Yeo supplies in a compact form nearly all that 
the practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered 
together from all quarters an immense amount of 
useful information within a comparatively small | 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 
Journal, Feb. 8, 1890. 



Yeo's Medical Treatment.— Just Ready. 

A Manual of Medical Treatment or Clinical Therapeutics. By 

I. Bueney Yeo, M. D., F. B. C. P., Prof, of Clinical Therapeutics in King's Coll., London. 
In two 12mo. yolumes containing 1275 pages, with illustrations. Cloth, $5.50. 

In this work disease is studied from the standpoint of treatment, the rational indi- 
cations for therapeutics being reached through an explanation of the causation and 
phenomena of disease, and the properties and mode of action of the agencies available for 
exerting favorable influence. The work is rich in selections of formulae used by well- 
known physicians. 



Richardson's Preventive Medicine. 

Preventive Medicine. By B. W. Bichardson, M. L\, LL. D., F. E. S., Fel- 
low of the Boyal Coll. of Phys., London. In one 8vo. vol. of 729 pp. Cloth, $4; leather, $5. 
There is perhaps no similar work written for j scholarly ; the discussion of the question of disease 
the general public that contains such a complete, | is comprehensive, masterly and fully abreast with 
reliable and instructive collection of data upon j the latest and best knowledge on the*subject, and 
the diseases common to the race, their origins, I the preventive measures advised are accurate, 
causes, and the measures for their prevention. ( explicit and reliable. — The American Journal of the 
The descriptions of diseases are -clear, chaste and | Medical Sciences, April, 1884. 



SCHREIBER'S MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EX- 
ERCISE. Translated by Walter Mexdelsox, 
M.D., of New York. In one 8vo. volume of 274 
pp., with 117 engravings. 

STILLE ON CHOLERA: Its Origin, History, 
Causation, Symptoms, Lesions, Prevention and 
Treatment. In one handsome 12mo. volume of 
163 pages, with a chart. Cloth, $1.25. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M.D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Throat, Nose, Lungs, Hind, Nerves. 



17 



Seiler on the Throat and Nose.— New (4th) Ed. Just Ready. 

A Handbook of Diagnosis and Treatment of Diseases of the 
Throat, Nose and Naso-Pharynx. By Carl Seeler, M. I)., Lecturer on 
Laryngoscopy in the University of Pennsylvania. New (4th) edition. Jn one handsome 

12kno. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. 

Though the work aims at brevity and concise- | gains rather than loses by that brevity. Another 
ness.and though much— in fact almost all— that is new chapter is on influenza and "Americas Grippe." 

theoretical has been omitted, vet thereby the work The size of the volume is most convenient and 



Lned in practical value and interest. Com- 
plete in an exhaustive sense it certainly is not; 
and yet in a more practical sense, and particularly 
from the therapeutic standpoint, its lack of com- 
pleteness is of the greatest value, since it casts 
aside the chaff and preserves the wheat, presenting 
it, moreover, in well-arranged, concise and, what 



the book-making excellent.— The New York Medi- 
cal Journal, May 13, 1893. 

The fourth edition of Seiler's admirable work 
should be warmly received by both practitioners 
and students as it well deserves. There is no 
special work of its size, on diseases of the throat 
and nose that contains more Information, yet it is 



is still more unusual, exceedingly readable form. | arranged in such a concise, compact form that it 

D new features appear in this edition, and of makes an exceedingly handy reference book for 

these the best is the chapter on intra nasal neo- the busy practitioner as well as a good text-book 

plasms, which, though brief, is yet sufficient, and I for the student.— Pacific Medical Record, May, 1893. 



Browne on the Throat and Nose. 

The Throat and Nose and Their Diseases. By Lennox Browne, 
F. E. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. 
Fourth and enlarged edition. In one imperial octavo volume of about 750 pages, with 
120 illustrations in color, and 235 engravings on wood. Cloth, $6.50. Just ready. 

A notice of the previous edition is appended. 
The beautiful and typical colored plates form ! tical text-book on diseases of the throat and nose 
a valuable and instructive atlas, the equal of which extant. We are glad to learn that it is being 
is not to be found in any modern work, treating ■, translated into French and German. — The Provin- 
of these subjects. Mr. Lennox Browne is to be ' cial Medical Journal, August 1, 1890. 
congratulated on having produced the best prac- | 



Tuke on the Influence of the Mind on the Body. 

Illustrations of the Influence of the Mind upon the Body in 
Health and Disease. Designed to elucidate the Action of the Imagination. By 
Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, 
etc. Xew edition. Thoroughly revised and rewritten. In one 8vo. volume of 467 pages, 
with 2 colored plates. Cloth, $3*00. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6, 1884. 



Clouston on Mental Diseases. 

Clinical Lectures on Mental Diseases. By Thomas S. Clouston, 
M. D., Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- 
dix, containing an Abstract of the Statutes of the United States and of the Several 
States and Territories relating to the Custody of the Insane. By Charles F. Folsom, 
M. D., Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo 
volume of 541 pages, with eight lithographic plates, four of which are colored. Cloth, $4. 
g^Dr. Folsom's Abstract also separate, in one 8vo. vol. of 108 pages, Cloth, $1.50. 
The descriptions of the diseases and cases are j and descriptions given as to the practical man- 
simple and practical, but true; and one sees as he | agement and care of the cases. We can heartily 
reads that they are given by one perfectly familiar recommend it to the student and busy general 
from daily observation with the cases and diseases practitioner. Dr. Folsom's work greatly increases 
he is speaking of. One feature of the book which the value of Dr. Clouston's book for the American 
commends it nighly, and which is not to be found : practitioner. — Archives of Medicine, June, 1884. 
in any other work on mental diseases, is the hints | 



Playfair on Nerve Prostration and Hysteria. 



By \V 



The Systematic Treatment of Nerve Prostration and Hysteria. 

S. Playfair, M. D., F. E. C. P. In one 12mo. volume of 97 pages. Cloth, $1.00. 



BROWNE ON KOCH'S REMEDY IN RELATION I 
TO THROAT CONSUMPTION. In one octavo j 
volume of 121 pages, with 45 illustrations, 4 of, 
which are colored, and 17 charts, Cloth, §1.50. 

FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 



valence in various Countries. Second and revised 
edition. In one 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH ON CONSUMPTION ; its Early and Reme- 
diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



18 Nervous and Jlental Diseases, Histology. 
Gray on Nervous and Mental Diseases. 

A Practical Treatise on Nervous and Mental Diseases. By 

Landon Carter Gray, M. D., Professor of Diseases of the Mind and Nervous System 
in the New York Polyclinic. In one very handsome octavo volume of 681 pages, with 
168 illustrations. Cloth, $4.50; leather, $5.50. 
A book that will be welcomed by the many who | terms is appended which will be found useful by 



desire a modern text-book on nervous diseases 
that is comprehensive and practical, and especial- 
ly full in the details of the treatment of these 
affections that are so often matters of perplexity 
to the general practitioner. It will be found, on 
this account, to meet the wants of a larg^ number 
perhaps better than would another equally meri 
torious text-book less full in this regard. Dr. Gray 
states in his preface, and it is evident to anyone 
perusing the work, that "especial care has been 
taken to make the therapeutical suggestions suf- 
ficiently detailed and precise to cover the varying 
stages, symptoms and complications of disease, as 
well as to follow the important indications afford- 
ed by differential diagnosis," and that "only that 
knowledge has been admitted to these ;;: pages 
which has stood the test of experience." Its style 
is clear and very readable, and the illustrations are 
numerous and excellent. A glossary of special 



the student. While it is intended as a text-book, 
not assuming any special knowledge on the part 
of its readers, the volume is full of valuable orig- 
inal matter that renders it a desirable addition to 
the library of the specialist in nervous and mental 
diseases.— American Jour, of Mental Sci. Feb., 1893. 
A highly successful effort to condense into a 
volume of reasonable size a practical knowledge 
of nervous and mental diseases. It is a book 
which the neurologist can consult with interest 
and advantage, and one which will be found par- 
ticularly u«eful to the student and general prac- 
titioner. The large space which throughout the 
work has been given to the discussion of symDto- 
matology and treatment will serve to make it 
popular, especially with busy workers. Dr. Gray's 
book will long hold its place as a standard treatise. 
— The Medical News, April 15, 1893. 



Ross on Diseases of the Nervous System. 

A Handbook on Diseases of the Nervous System. By James 
Boss, M. D., F. B. C.P., LL.D., Senior Assistant Physician to the Manchester Eoyal 
Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50 ; leather, $5.50. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 



for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner.— Edinburgh MedicalJournal, Jan. 1887. 



Hamilton on Nervous Diseases.— Second Edition. 

Nervous Diseases ; Their Description and Treatment. By Allen McLane 
Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, 
Blackwell's Island, N. Y. Second edition, thoroughly revised and rewritten. In one 
octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. 

When the first edition of this good book appeared characterized this book as the best of its kind in 
we gave it our emphatic endorsement, and the 
present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old. — 
Alienist and Neurologist, April, 1882. 



Savage on Insanity and Allied Neuroses. 

Insanity and Allied Neuroses, Practical and Clinical. By George 
H. Savage, M. D., Lecturer on Mental Diseases at Guy's Hospital, London. In one 
12mo. vol. of 551 pp., with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, p. 30. 

Klein's Histology.— Fourth Edition. 

Elements of Histology. By E. Klein, M. D., F. B. S., Joint Lecturer on 
General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, 
London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp 
cloth, $1.75. See Students' Series of Manuals, page 30. 

The large number of editions through which 
Dr. Klein's little handbook of histology has run 
since its first appearance in 1883 is ample evidence 
that it is appreciated Jjy the medical student and 
that it supplies 



a definite want. The clear and 



concise manner in which it is written, the 
absence of debatable matter, of conflicting views, 
added to the convenient size of the book and its 
moderate price, will account for its undoubted 
success. — Medical Chronicle, Feb., 1890. 



Schafer's Histology.— Third Edition. 

The Essentials of Histology. By Edward A. Schafer, F. K. S., Jodrell 
Professor of Physiology in University College, London. New (third) edition. In one 
octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very 
handsome octavo volume. 

JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 



American Edition. In one handsome octavo 
volume of 340 pages. Cloth, $3.25. 
PEPPER'S SURGICAL PATHOLOGY. In one 
pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Pathology, Histology, Bacteriology, 



19 



Gibbes' Practical Pathology and Morbid Histology. 

Practical Pathology and Morbid Histology. By IIeneage Gibbes, 
M. D.. Professor of Pathology in the University of Michigan, Medical Department. In 
one very handsome Svo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, $2.75. 



This is, in part, an expansion of the little work 
published by the author some years ago, and his 
acknowledged skill as a practical microscopist will 
give weight to his instructions. Indeed, in ful- 
ness of directions as to the modes of investigating 
morbid tissues the book leaves little to be desired. 



The work is throughout profusely illustrated with 
reproductions of micro-photographs. We may 
say that the practical histologist will gain much 
useful information from the book.— The London 
Lancet, January 23, 1892. 



Abbott's Bacteriology. 

The Principles of Bacteriology : a Practical Manual for Students and 

Phvsicians. By A.C.Abbott, M. D., First Assistant, Laboratory of Hygiene, University 

of Pennsylvania, Philadelphia. In one 12mo. vol. of 259 pp., with 32 illus. Cloth, $2.00. 

To a person desiring to learn the technique of | judgment in the selection and arrangement of 

bacteriological work, we cannot recommend any j his material. The student who follows it closely 



work which will be more suitable than the one 
before us Th« fault which can be found with 
most of the works we have met with on this sub- 
ject, is that they are too extended for the use of a 
student or practitioner beginning the subject and 
yet are not sufficiently large to allow of an ex- 
haustive treatment. Dr. Abbott has shown great 



will be in a condition to carry forward the work 
forhimself. Medical practitionersgenerallycould 
rt^ad the work with profit, especially the chapters 
on sterilization and disinfection, and those on 
tuberculosis and diphtheria in the second part. — 
The Canadian Practitioner, Nov. 1, 1892. 



Senn's Surgical Bacteriology.— Second Edition. . 

Surgical Bacteriology. By Nicholas Senn, M. D., Ph. D., Professor of 
Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome 
octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. 



The book is really a systematic collection in the 
most concise form of such results as are published 
in current medical literature by the ablest workers 
in this field of surgical progress; and to these are 
added the author's own views and the results of 
his clinical experience and original investigations. 
The book is valuable to the student, but its chief 
value lies in the fact that such a compilation 



makes it possible for the busy practitioner, whose 
time for reading is limited and whose sources of 
information are often few, to become conversant 
wiih the most modern and advanced ideas in sur- 
gical pathology, which have "laid the foundation 
for the wonderful achievements of modern sur- 
gery." — Annals of Surgery, March, 1892. 



Green's Pathology and Morbid Anatomy.— Seventh Edition. 

Pathology and Morbid Anatomy. By T. Henry Green, M. D., Lecturer 
on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 
Sixth American from the seventh revised English edition. Octavo, 539 pages, with 167 
engravings. Cloth, $2.75. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances of 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its favor. — Cincinnati Medical News, Oct. 



Payne's General Pathology. 



A Manual Of General Pathology. Designed as an Introduction to the 
Practice of Medicine. By Joseph F. Payne, M. D., F. R. C. P., Senior Assistant Physi- 
cian and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 
524 pages, with 152 illustrations and a colored plate. Cloth, $3.50. 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



cal factors in those diseases now with reasonable 
certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth the price of the 
book, several times over, to every student of 
pathology.— St. Louis Med. and Surg. Jour., Jan. '89. 



Coats' Treatise on Pathology. 

A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- 
gist to the Gla.sgow Western Infirmary. In one very handsome octavo volume of 829 
pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

Medical students as well as physicians, who 
desire a work for study or reference, that treats 
the subjects in the various departments in a very 
thorough manner, but without prolixity, will cer 



tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 
recent discoveries, exhibits, in an interesting 



manner, the changes from a normal condition 
effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions.— Cincinnati Medical News, Oct. 1883. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



20 Surgery. 

Roberts' Modern Surgery. 

The Principles and Practice of Modern Surgery. For the use of 

Students and Practitioners of Medicine and Surgery. By John B. Koberts, M. D., Pro- 
fessor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Princi- 
ples and Practice of Surgery in the Woman's Medical College of Pennsylvania. Lecturer 
in Anatomy in the University of Pennsylvania. In one very handsome octavo volume 
of 780 pages, with 501 illustrations. Cloth, $4.50; leather, §5.50. 

This work is a very comprehensive manual upon I vanced doctrines and methods of practice of the 
general surgery, and will doubtless meet with a j present day. Its general arrangement follows 
favorable reception by the profession. It ha* a | this rule, and the author in his desire to be con- 



thoroughly practical character, the subjects are 
treated with rare judgment, its conclusions are in 
accord with those of the leading practitioners of 
the art, and its literature is fully up to all the ad- 



cise and practical is at times almost dogmatic, but 
this is entirely excusable considering the admira- 
ble manner in which he has thus increased the 
usefulness of his work. — Med. Rec, Jan. 17, 1891. 



Ashhurst's Surgery.— Fifth Edition. 

The Principles and Practice of Surgery. By John Ashhurst, 
Jr., M. D., Barton Professor of Surgery and Clinical Surgery in the Univ. of Penn., Sur- 
geon to the Penn. Hosp., Philadelphia. Fifth edition, enlarged and thoroughly revised. 
In one octavo volume of 1144 pages, with 642 illus. Cloth, $6.00 ; leather, $7.00. 

A complete and most excellent work on surgery. I peat that commendation. The student, we believe, 
It is only necessary to examine it to see at once could not get a better book for obtaining a corn- 
its excellence and real merit either as text-book I prehensive knowledge of surgery. The latest 
for the student or a guide for the general practi- I advances are referred to with sufficient clearness 
tioner. It fully considers in detail every surgical i to stimulate to further study, and the teaching of 
injury and disease to which the body is liable, and j the book is eminently conservative, but always 
every advance in surgery worth noting is to be j judicious. As usual Dr. Ashhurst has included 
found in its proper place. It is unquestionably the many valuable statistical tables, which have been 
best and most complete single volume on surgery, ] revised up to date of preparation. No better 
in the English language, and cannot but receive j single volume on surgery can be found in the 
that continued appreciation which its merits justly j English language, and they are quite numerous, 
demand. — Southern Practitioner, Feb. 1890. i We commend it to our readers as a resume of the 

In reviewing a previous edition we highly com- \ best modern methods in general and of American 
mended the work of Ashhurst to the student and ' practice in particular. — The New Orleans Medical 
practitioner as a text book. We can heartily re- | and Surgical Journal, Sept. 1890. 



Druitt's Modern Surgery.— Twelfth Edition. 

Manual of Modern Surgery. By Kobert Druitt, M. B. C. S. Twelfth 
edition, thoroughly revised by Stanley Boyd, M. B., B. S., F. R. C. S. In one 8vo. 
volume of 965 pages, with 373 illustrations. Cloth, $4.00; leather, $5.00. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 



appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. — Cincinnati Medical 
News, September, 1887. 



Gross' System of Surgery.— Sixth Edition. 

A System of Surgery. By Samuel D. Geoss, M. D., LL. D., Emeritus 
Professor of Surgery in the Jefferson Medical College of Philadelphia. Sixth edition. 
In two large imperial octavo volumes containing 2382 pages, illustrated with 1623 
engravings. Leather, raised bands, $15.00 ; half Kussia, $16.00. 

Young's Orthopaedic Surgery.— In Press. 

A Manual of Orthopaedic Surgery, for Students and Practi- 
tioners. By James K. Young, M. D., Instructor in Orthopaedic Surgery, University of 
Pennsylvania, Philadelphia. In one 12mo. vol. of about 400 pp., fully illustrated. 

Butlin on the Tongue. 

Diseases of the Tongue. By Henry T. Butlin, F. E. C. S., Assistant 
Surgeon to St. Bartholomew's Hospital, LondoD. In one 12mo. volume of 456 pages, 
with S colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, p. 30. 

Gould's Surgical Diagnosis. 

Elements of Surgical Diagnosis. By A. Pearce Goued, M. S., M. B., 
F. E. C. S., Assistant Surgeon to Middlesex Hospital, London. In one pocket-size 12mo. 
volume of 589 pages. Cloth, $2.00. See Students' Series of Manuals, page 30. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 

GANT'S STUDENT'S SURGERY. By Frederick 
James Gant, F. R. C. S. Square octavo, S48 pages, 
159 engravings. Cloth, $3.75. 



MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American edition. In one large 8vo. 
vol. of 682 pp.. with 364 illustrations. Cloth, $3.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh ed. In one 
8vo. vol. of 638 pages, with 340 illus. Cloth, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Surgery — (Continued). 



21 



Erichsen's Science and Art of Surgery.— Eighth Edition. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, 
Diseases and Operations. By John E. Ericiisen, F. R. S.« F. R. ( I.S., Professor of Sur- 
gery in University College, London, etc. From the eighth and enlarged English edition. 
In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 



through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 



of the former edition has been dropped and no 
discovery, device or improvement which has 
marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
—Louisville Medical News, Feb. 14, 1885. 



Bryant's Practice of Surgery.— Fourth Edition. 

The Practice of Surgery. By Thomas Bryant, F. K. C. S., Surgeon and 
Lecturer on Surgery at Guy's Hospital, London. Fourth American from the fourth and 
revised English edition. In one large and very handsome imperial octavo volume of 1040 
pages, with 727 illustrations. Cloth, $6.50 ; leather, $7.50. 



The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 



place the work among the highest order of text- 
books for the medical student. Almost every 
topic in surgery is presented in such a form as to 
enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical.-CTiicacro Med. Jour, and Examiner, Apr. '86. 



Wharton's Minor Surgery and Bandaging.— 2d Ed. Just Ready. 

Minor Surgery and Bandaging. By Henry R. Wharton, M. D., 

Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 
529 pages, with 416 engravings, many being photographic. Cloth, $3.00. 
A notice of the previous edition is appended. 

rious established operations are described in detail. 
Hence this work becomes a most valuable compan- 
ion-book to any of the more pretentious treatises 
on surgery, where simply the general advice is 
given to bandage, amputate, intubate, operate, etc. 
For the student and young surgeon, it is a very 
valuable instruction book from which to learn how 



This new work must take a first rank as soon as 
examined. Bandaging is well described by words, 
and the methods are illustrated by photographic 
drawings, so as to make plain each step taken in 
the application of bandages of various kinds to dif- 
ferent parts of the body and extremities — including 
the head. The various operations are likewise de- 
scribed and illustrated, so that it would seem easy 
for the tyro to do the gravest amputation. The va- 



to do what may be advised, in general terms, to be 
done.— Virginia Medical Monthly, October 1891. 



Treves' Operative Surgery.— Two Volumes. 

A Manual of Operative Surgery. By Frederick Treves, F. K. C. S., 
Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes 



containing 1550 pages, with 422 engravings. 
Mr. Treves in this admirable manual of opera- 
tive surgery has in each instance practically 
assumed that operation has been decided upon 
and has then proceeded to give the various opera- 
tive methods which may be employed, with a 
criticism of their comparative value and a detailed 
and careful description of each particular stage 
of their performance. Especial attention has been 
paid to the preparatory treatment of the patient 
and to the details of the after treatment of the 
case, and this is one of the most distinctive among 
the many excellent features of the book. We have 
no hesitation in declaring it the best work on the 
subject in the English language, and indeed, in 
many respects, the best in any language. It can- 



Complete work, cloth, $9.00; leather, $11.00. 
not fail to be of the greatest use both to practical 
surgeons and to those general practitioners who, 
owing to their isolation or to other circumstances, 
are forced to do much of their own operative work. 
We feel called upon to recommend the book so 
strongly for the excellent judgment displayed in 
the arduous task of selecting from among the 
thousands of varying procedures those most 
worthy of description ; for the way in which the 
still more difficult task of choosing among the 
best of those has been accomplished; and for the 
simple, clear, straightforward manner in which 
the information thus gathered from all surgical 
literature has been conveyed to the reader. — 
Annals of Surgery, March, 1892. 

In one 



Treves' Student's Handbook of Surgical Operations. 

square 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50. 

A Manual' of Surgery. In Treatises by Various Authors, edited by Fred- 
erick Treves, F. B. C. S. In three 12mo. volumes, containing 1866 pages, with 213 
engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. 



We have here the opinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, 
with 60 illus. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. 

Holmes' System of Surgery.— American Edition. 

A System of Surgery; Theoretical and Practical. By Various 
Authors. Edited by Timothy Holmes, M. A. American edition, revised and re- 
edited by John H. Packard, M. D. Three large octavo vols., 3137 pp., 979 illus. on wood 
and 13 lith. plates. Per set, cloth, $18 ; leather, $21. Subscription only. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



22 Surgery — (Continued), Fractures, Dislocations. 



Smith's Operative Surgery.— Revised Edition. 

The Principles and Practice of Operative Surgery. By Stephen 
Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. 
Second and thoroughly revised edition. In one verv handsome octavo volume of 892 
pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00. 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. The book is a compendium 
for the modern surgeon. The present edition is 
much enlarged, and the text has been thoroughly 
revised, so as to give the most improved methods 
in aseptic surgery, and the latest instruments 
known for operative work. It can be truly said that 
as a handbook for the student, a companion for the 



surgeon, and even as a book of reference for the 
physician not especially engaged in the practice 
of surgery, this volume will long hold a most 
conspicuous place, and seldom will its readers, no 
matter how unusual the subject, consult its pages 
in vain. Its compact form, excellent print, num- 
erous illustrations, and especially its decidedly 
practical character, all combine to commend it. — 
Boston Medical and Surgical Journal, May 10, 1888. 



Holmes' Treatise on Surgery.— One Volume. 

A Treatise on Surgery ; Its Principles and Practice. By Timothy 
Holmes, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. 
From the fifth English edition, edited by T. Pickering Pick, F. E. C. S. In one 
octavo volume of 997 pages, with 428 illustrations. Cloth, $6.00 ; leather, $7.00. 



To the younger members of the profession and 
to others not acquainted with the book and its 
merits, we take pleasure in recommending it as a 
surgery complete, thorough, well- written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the surgeon's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient. — Pacific 
Medical Journal, July, 1889. 



Hamilton on Fractures and Dislocations.— Eighth Edition. 

A Practical Treatise on Fractures and Dislocations. By Frank 
H. Hamilton, M. D., LL. D., Surgeon to Bellevue Hospital, New York. New (8th) edi- 
tion, revised and edited by Stephen Smith, M. D. , Prof, of Clinical Surgery in Univ. ot 
City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50 ; leather, $6.50. 



Its numerous editions are convincin g proof if any 
is needed, of its value and popularity. It is pre- 
eminently the authority on fractures and disloca- 
tions, and universally quoted as such. In the new 
edition it has lost none of its former worth. The 
additions it has received by its recent revision make 
it a work thoroughly in accordance with modern 
practice, theoretically, mechanica'ly, aseptically. 
The task of writing a complete treatise on a sub- 
ject of such magnitude is no easy one. Dr. Smith 



has aimed to make the present volume a correct 
exponent of our knowledge of this department 
of surgery. In examining. the volume one is at 
once struck; with the evidence of the vast amount 
of labor its compilation and reconstruction must 
have necessitated. The more one reads the more 
one is impressed with its completeness. The work 
has been accomplished, and has been done clearly, 
concisely, excellently well.— Boston Medical and 
Surgical Journal, May 26, 1892. 



Stimson's Operative Surgery.— Second Edition. 

A Manual of Operative Surgery. By Lewis A. Stimson, B. A., M. D., 
Professor of Clinical Surgery in the University of the City of New York. Second edi- 
tion. In one royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 



The author knows the difficult art of condensa- 
tion. Thus the manual serves as a work of 
reference, and at the same time as a handy 
guide. It teaches what it professes, the steps 
of operations. In this edition Dr. Stimson has 
sought to indicate the changes that have been 
effected in operative methods and procedures by 



the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



Stimson on Fractures and Dislocations. 

A Treatise on Fractures and Dislocations. By Lewis A. Stimson, 
M. D. In two handsome octavo volumes. Vol. L, Fractures, 582 pages, 360 illustra- 
tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, 
cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. 



The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 



exhibits the surgery of Dislocations as it is taught 
and practised by the most eminent surgeons of the 
present time. Containing the results of such ex- 
tended researches it must for a long time be re- 
garded as an authority on all subjects pertaining 
to dislocations. Every practitioner of surgery will 



on the subject, and its companion on Dislocations feel it incumbent on him to have it for constant 
will no doubt be similarly received. This volume j reference. — Cincinnati Medical News, May, 1888. 

Pick on Fractures and Dislocations. 

Fractures and Dislocations. By T. Pickering Pick, F. E. C. S., Sur- 
geon to and Lecturer on Surgery at St. George's Hospital, London. In one 12mo. vol. 
of 530 pp., with 93 illus. Limp cloth, $2.00. See Series of Clinical Manuals, page 30. 

Marsh on the Joints. 

Diseases of the Joints. By Howard Marsh, F. E. C. S., Senior Assistant 
Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 468 pages, with 
64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Ophthalmology, Otology. 23 



Norris & Oliver's Ophthalmology.— Just Ready. 

A Text-Book of Ophthalmology. By William F. Norris, M. D., 
Professor of Ophthalmology in the University of Pennsylvania, and Chables A. Oliver, 

M. D., Surgeon to Wills' Eye Hospital, Philadelphia. In one very handsome octavo 
vol. of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $G. 

The preparation of this magnificent work has engaged its eminent authors during 
a period exceeding seven years, their effort being to produce a guide for the student and 
practitioner which should represent the most advanced state of its science in the clearest 
possible manner. The volume embodies not only the results of large personal experience, 
but also of most extensive acquaintance with the vast and rich literature of its department. 
By a careful selection of material and the employment of a terse style the authors have 
secured the advantages of clearness and comprehensiveness in a volume of convenient size. 
The series of illustrations is singularly rich and is thoroughly in keeping with the 
literary material which it embellishes. The volume is assured of the foremost position 
as a text-book and work of reference. 

Berry on the Eye.— New Edition. Just Ready. 

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. 
By George A. Berry, M. B., F. B. C. S., Ed., Ophthalmic Surgeon, Edinburgh Royal 
Infirmary. New (second) edition. In one octavo volume of 750 pages, with 197 illustra- 
tions, mostly lithographic. Cloth, $8.00. 

The thorough revision of Berry's book has re- 1 close connection with the matter to which they 
suited in a volume largely increased in text and relate — an obvious point of convenience for the 
illustrations, and the practical character has been reader. It is an admirable book and will hence- 
maintained. The work is distinguished by its ; forth occupy and hold its place as one of the best 
profusion of beautifully colored illustrations which treatises upon the subject we have. — Annals of 
are scattered throughout the text and placed in | Ophthalmology and Otology, July, 1893. 

Juler's Ophthalmic Science and Practice. 

A Handbook of Ophthalmic Science and Practice. By Hexry E. 
Juler, F. B. C. S., Senior Assistant Surgeon, Royal Westminster Ophthalmic Hospital; 
Late Clinical Assistant, Moorfields, London. English edition. Handsome 8vo. volume 
of 442 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of Jaeger 
and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50 ; leather, $6.50. 

The second edition of Mr. Juler's work has, we ] ject of ophthalmology. We would especially refer 
know, been anxiously awaited. The author has our readers to the chapter on the refraction of the 
made numerous alterations and additions, alike in J eye, a subject of essential importance in the diag- 
the text and in the illustrations, so that the reader ' nosis and treatment of optical errors. We conn- 
is provided in a readable form, and with a concise- : dently anticipate a most cordial welcome for this 
ness thoroughly compatible with accuracy of de- ! work alike by students and practitioners of medi- 
scription, with all that is most modern on the sub- j cine. — The Practitioner, July, 1893. 

Field's Manual of Diseases of the Ear.— Just Ready. 

A Manual of Diseases of the Ear. By Geokge P. Field, M. E, C. S , 

Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, 

London. In one octavo of 391 pp., with 73 engravings and 21 colored plates. Cloth, $3.75. 

This book is written by an authority on this I book for the student, and a safe and reliable guide 

subject, and may be recommended as a good textr | for the practitioner. — Edinburgh Med. Jour. ,May'93. 

Burnett on the Ear.— Second Edition. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical 
Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, 
A. M., M. D., Professor of Otology in the Philadelphia Polyclinic ; President of the 
American Otological Society. Second edition. In one handsome octavo volume of 580 
pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

Politzer's Text-Book of Diseases of the Ear.— New Ed. In Press 

A Text-Book of the Diseases of the Ear and Adjacent Organs. 
By Dr. Adam Politzer, Imperial-Royal Professor of Aural Therapeutics in the Uni- 
versity of Vienna. In one large octavo vol. of about 800 pages, with about 300 engravings. 

Nettleship on the Eye.— Fifth Edition. 

Diseases of the Eye. By Edward Nettleship, F. R. C. S., Ophthalmic 
Surgeon at St. Thomas' Hospital, London. Surgeon to the Royal London (Moorfields) 
Ophthalmic Hospital. Fourth American from the fifth English edition, thor- 
oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College, 
Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from 
Snellen's test-types and formulae, and a colored plate. Cloth, §2.00. 

This is a well-known and a valuable work. It knowledge to be present which seems to be as- 
was primarily intended for the use of students, j sumed in some of our larger works, is not tedious 
and supplies" their needs admirably, but it is as from over-conciseness, and yet covers the more 
useful for the practitioner, or indeed more so. It important parts of clinical ophthalmology. — New 
does not presuppose the large amount of recondite York Medical Journal, December 13, 1890. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



24 Urinary & Renal Dis., Dentistry, Ophthal. 
Roberts on Urinary and Renal Diseases.— Fourth Edition. 

A Practical Treatise on Urinary and Renal Diseases, including 
Urinary Deposits. By Sir William Boberts, M. D., Lecturer on Medicine in the 
Manchester School of Medicine, etc. Fourth American from the fourth London edi- 
tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 



It may be said to be the best book in print on the 
subject of which it treats. — The American Journal 
of the Medical Sciences, Jan. 1886. 

It is an unrivalled exposition of everything 
which relates directly or indirectly to the diagno- 
sis, prognosis and treatment of urinary diseases, 



and possesses a completeness not found else- 
where in our language in its account of the differ- 
ent affections.— Manchester Med. Chron., July, '85. 
The value of this treatise as a guide book to the 
physician in daily practice can hardly be over- 
estimated. — Medical, Record, July 31, 1886. 



By 



Purdy on Blight's Disease and Allied Affections. 

Bright's Disease and Allied Affections of the Kidneys 

Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases in the Chi- 
cago Polyclinic. In 'one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. 

short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 
1886. 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



Morris on Surgical Diseases of the Kidney. 

Surgical Diseases of the Kidney. By Henry Morris, F. E. C. S., 
Surgeon to Middlesex Hospital, London. 12mo., 554 pages, with 40 woodcuts, and 
6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 30. 

Thompson on the Urinary Organs. 

Lectures on Diseases of the Urinary Organs. By Sir Hexry 
Thompson, Professor of Clinical Surgery to University College Hospital, London. 
Second American from the third English edition. Octavo, 203 pp., 25 illus. Cloth, $2.25. 

Thompson on the Pathology and Treatment of Stricture of the 
Urethra and Urinary Fistulse. From the third English edition. In one octavo 
volume of 359 pages, with 47 engravings and 3 plates. Cloth, $3.50. 

The American System of Dentistry. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M.D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. For sale by subscription only. 
As an encyclopsedia of Dentistry it has no su- 

f>erior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
Greatest value to all engaged in the practice of 
entistry. — American Jour. Dent. Sci., Sept. 1886. 
A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it. — Odonto- 
graphy Journal, Jan. 1887. 



Coleman's Dental Surgery.— American Edition. 

A Manual of Dental Surgery and Pathology. By Alfred Coleman 
L. E. C. P., F. E. C. S., Exam. L. D. S., Lecturer on Dental Surgery at St. Bartholomew's 
Hospital, London. Thoroughly revised and adapted to the use of American Students, by 
by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadel- 
phia Dental College. Octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

Carter & Frost's Ophthalmic Surgery. 

Ophthalmic Surgery. By E. Brudenell Carter, F. E. C. S., Lecturer 
on Ophthalmic Surgery at St. George's Hospital, London, and W. Adams Frost, F. E C. S., 
Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London. In one 12mo. 
volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appen- 
dix of formulae. Cloth, $2.25. See Series of Clinical Manuals, page 30. 



BASHAM ON RENAL DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. In 
one 12mo. vol. of 304 pages, with 21 illustrations. 
Cloth, 82.00. 

WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 



titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 

LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS : Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Impotence, Sterility, Venereal, Skin, 



25 



Gross on Impotence, Sterility, etc.— Fourth Edition. 

A Practical Treatise on Impotence, Sterility, and Allied Dis- 
orders of the Male Sexual Organs. By Samuel W. Gross, A.M., M. D., 
LL. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson 
Medical College of Philadelphia. Fourth edition, thoroughly revised by F. K. Sturgis, 
M. D., Prof, of Diseases of the Genito-Urinary Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one 8vo. vol. of 165 pages, with 18 illus. Cloth, $1.50. 



Three editions of Professor Gross' valuable book 
have been exhausted, and still the demand is 
unsupplied. Dr. Sturgis has revised and added 
to the previous editions, and the new one appears 
more complete and more valuable than before. 
Four important and generally misunderstood sub- 
jects are treated— impotence, sterility, spermator- 



rhoea, and prostatorrhcea. The book is a practical 
one and in addition to the scientific and very in- 



there are lines of treatment laid down that an 



teresting discussions on etiology, symptoms, etc 

id d( 
practitioner can follow and which have met 
success in the hands of author and editor. — Medi- 
cal Record, Feb. 25, 1891. 



it'i. 



Taylor on Venereal Diseases.— Sixth Edition. Preparing. 

The Pathology and Treatment of Venereal Diseases. Including the 

results of recent investigations upon the subject. By Robert W. Taylor, A. M., M. D., 
Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, 
New York. Being the sixth edition of Bumstead and Taylor, rewritten by Dr. Taylor. , 
Large 8vo. volume, about 900 pages, with about 150 engravings, as well as numerous 
chromo-lithographs. In active preparation. A notice of the previous edition is appended. 

It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language | 



upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — Am. Jour, of the Med. Sciences, Jan. 1884. 



Culver & Hayden's Manual of Venereal Diseases. 

A Manual of Venereal Diseases. By Everett M. Culver, M. D. 
Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James 
R. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- 
geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75. 

This book is a practical treatise, presenting in a 
condensed form the essential features of our pres- 
ent knowledge of the three venereal diseases, 



syphilis, chancroid and gonorrhea. We have ex- 
amined this work carefully and have come to the 
conclusion that it is the most concise, direct and 
able treatise that has appeared on the subject of 



venereal diseases for the general practitioner to 
adopt as a guide. The general practitioner needs 
a few simple, concise and clearly presented laws, 
in the execution of which he cannot fail either to 
cure or prevent the ravages of the maladies in 
question and their direful results. — Buffalo Medical 
and Surgical Journal, May, 1892. 



Cornil on Syphilis. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. 
Cornil, Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hos- 
pital. Specially revised by the Author, and translated with notes and additions by J. 
Henry C. Simes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa., 
and J. William White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one 
handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 



The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one.— The London Practt' 
tioner, Jan. 1882. 



Hutchinson on Syphilis. 

Syphilis. By Jonathan Hutchinson, F. E. S., F. E. C. S., Consulting Sur- 
geon to the London Hospital. In one 12mo. volume of 542 pages, with 8 chromo- 
lithographs. Cloth, $2.25. See Series of Clinical Manuals, page 30. 

Those who have seen most of the disease and facts and suggestions which abound in these 
those who have felt the real difficulties of diagno- pages.— London Medical Record, Nov. 12, 1887. 
sis and treatment will most highly appreciate the 



Gross on the Urinar/ Organs. 



A Practical Treatise on the Diseases, Injuries and Malforma- 
tions of the Urinary Bladder, the Prostate Gland and the Urethra. 
By Samuel D. Gross, M. D., LL. D., D. C. L. etc. Third edition, thoroughly revised 
by Samuel, W. Gross, M. D. In one octavo vol. of 574 pp., with 170 illus. Cloth, $4.50. 



FOX'S EPITOME OF SKIN DISEASES. WITH 
FORMULAE. Third edition, revised and en- 
larged. In one 12mo. vol. of 238 pp. Cloth, (1.25. 

HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, 
with plates. Cloth, $2.25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 



LEE'S LECTURES ON RVPHTLIS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING 
THE ORGANS OF GENERATION. In one 
Svo. volume of 24fi pages. Cloth. $2.25. 

WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE AND DISEASES OF THE SKIN. 
In one handsome small octavo volume of 535 
pages. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



26 Venereal and Skin Diseases. 

Taylor's Clinical Atlas of Venereal and Skin Diseases. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diag- 
nosis, Prognosis and Treatment. By Robert W. Taylor, A. M., M. D., Clinical Pro- 
fessor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York ; 
In eight large folio parts, and comprising 58 beautifully colored plates with 213 figures, 
and 431 pages of text with 85 engravings. Price per part, $2.50. Bound in one volume, 
half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 

It would be hard to use words which would per- student can examine these true-to-life chromo-lith- 
spicuously enough convey to the reader the great , ographs. Comparing the text to a lecturer, it is 
value of this Clinical Atlas. This Atlas is more more satisfactory in exactness and fullness than 
complete even than an ordinary course of clinical he would be likely to be in lecturing over a single 
lectures, for in no one college or hospital course i case. Indeed, this Atlas is invaluable to the gen- 
is it at all probable that all of the diseases herein eral practitioner, for it enables the eye of the 
represented would be seen. It is also more ser- ; physician to make diagnosis of a given case of 
viceable to the majority of students than attend- skin manifestation by comparing the case with 
ance upon clinical lectures, for most of the the picture in the Atlas, where will be found also 
students who sit on remote seats in the lecture the text of diagnosis, pathology, and full sections 
hall cannot see the subject as well as the office \ on treatment.— Virginia Medical Monthly, Dec. 1889. 



Jackson's Ready-Reference Handbook of Skin Diseases. 

The Ready-Reference Handbook of Diseases of the Skin. By 

George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College 
of the New York Infirmary. In one 12mo. volume of 544 pages, with 50 illustrations 
and a colored plate. Cloth, $2.75. 



Intended to serve as a reference book for the 
general practitioner, "no attempt has been made 
to discuss debatable questions," and "hence pa- 
thology and etiology do not receive as full consid- 
eration as symptomatology, diagnosis and treat- 
ment." The alphabetical arrangement of diseases, 
so universal now in books of this class, has been 
followed by Dr. Jackson. After a short and con- 
densed account of the anatomy and physiology of 



the skin, the author presents a few notes of com- 
mon and practical importance on diagnosis and 
therapeutics, which are followed by his well- 
known and graphic derroatological "Don'ts." 
Part II. treats in alphabetical order of the dis- 
eases of the skin and their management. This 
book seems to us the best cf its class that has 
yet appeared. — Boston Medical and Surgical Jour- 
nal, May 18, 1893. 



Pye-Smith on Diseases of the Skin.— Just Ready. 

A Handbook of Diseases of the Skin. By P. H. Pye-Smith, M. D., 
F. R. S , Physician to Guy's Hospital, London. In one octavo volume of 407 pages, 
with 26 illustrations, 18 of which are colored. Cloth, $2.00. 

It is a plain, practical treatise on dermatology, I advances made in this department of medicine, 
written lor the student and general practitioner , he pays a merited compliment to the "important 
by a general practitioner of broad experience in contributions made by the newest school of 
the special subject of which he writes. He simpli- dermatology, that of America." — Pitttburg Medical 
fies the nomenclature, and succeeds in removing Record, June, 1893. 
much of the difficulty. After reviewing the recent 



Hardaway's Manual of Skin Diseases. 

Manual of Skin Diseases. With Special Keferenceto Diagnosis and Treat- 
ment. For the use of Students and General Practitioners. By W. A. Hardaway, M. D., 
Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. 
Dr. Hardaway's large experience as a teacher embraces all essential points connected with the 
and writer has admirably fitted him for the diffi- diagnosis and treatment of diseases of the skin, 
cult task of preparing a book which, while sum- and we have no hesitation in commending it as 
ciently elementary for the student is yet suffi- the best manual that has yet appeared in this 
ciently thorough and comprehensive to serve as a department of Medicine.— Journal of Cutaneous 
book of reference for the general practitioner. It | and Genito- Urinary Diseases. 

Hyde on the Skin.— Third Edition. Just Ready. 

A Practical Treatise on Diseases of the Skin. For the use of Students 
and Practitioners. By J. Kevins Hyde, A. M., M. D., Professor of Dermatology and Ven- 
ereal Diseases in Eush Medical Cc liege, Chicago. Third edition. In one octavo volume 
of 80'2 pages, with 9 colored plates and 108 illustrations. 
A notice of the previous edition is appended. 
His treatise is like his clinical instruction, I The prescriptions and formula? are given in both 
admirably arranged, attractive in diction, and common and metric systems. Altogether it is a 
strikingly practical throughout. No clearer de- | work exactW fitted to the needs of a general pre- 
scription of the various primary and consecutive j titioner, and no one will make a mistake in pur- 
lesions of the skin is to be met with anywhere. ! chasing it. — Med. Press of Western N. Y., June, 1888. 

Jamieson on Diseases of the Skin.— Third Edition. 

Diseases of the Skin. A Manual for Students and Practitioners. By 
W. Allan Jamieson, M. D., Lecturer on Diseases of the Skin, School of Medicine, Edin- 
burgh. Third edition, revised and enlarged. In one octavo volume of 656 pages, with 
woodcut and 9 double-page chromo- lithographic illustrations. Cloth, $6.00. 



The first edition of this work appeared in 1888, 
and the following year a second. The scope of the 
work is essentially clinical, little reference being 
made to pathology or disputed theories. Almost 



record of personal experience. The pages are 
filled with interest to all thosp occupied with skin 
diseases. The general practitioner will find the 
book of great value in matters of diagnosis and 



every subject is followed by illustrative cases treatment. The latter is quite up to date, and the 
taken from the author's practice, and the reader i formulae have been selected with care. — Medical 
is constantly reminded that he has before him a 1 Record, April 9, 1892. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Diseases of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 



These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor pre- 
sents a monograph upon his special topic, so that 
everything in the way of history, theory, methods, 
and results is presented to our "fullest need. As a 
work of general reference, it will be found remarka- 
bly full and instructive in every direction of 
inquiry.— The Obstetric Gazette, September, 1889. 

One is at a loss to know what to say of this vol- 
ume, for fear that just and merited praise maybe 
mistaken for flattery. The papers of Drs. Engel- 
mann, Martin, Hirst, Jaggard and Reeve are incom- 
parably beyond anything that can be found in 
obstetrical works.— Journal of the American Medical 
Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement:— "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 



United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors." 
It, like the other, has been written exclusively 
by American physicians who are acquainted with 
all the characteristics of American people, who are 
well informed in regard to the peculiarities of 
American women, their manners, customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy- 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing. — 
Cincinnati Med. News, July, 1887. 



Emmet's Gynaecology — Third Edition. 

The Principles and Practice of Gynaecology ; For the use of Students 
and Practitioners of Medicine. By Thomas Addis Emmet, M. D., LL. D., Surgeon to 
the Woman's Hospital, New York, etc. Third edition, thoroughly revised. In one 
large and very handsome 8vo. vol. of 880 pp., with 150 illus. Cloth, $5 ; leather, $6. 
We are in doubt whether to congratulate the i the privilege thus offered them of perusing the 
author more than the profession upon the appear- \ views and practice of the author. His earnestness 
ance of the third edition of this well-known work. j of purpose and conscientiousness are manifest. 
Embodying, as it does, the life-long experience of ; He gives not only his individual experience but 
one who has conspicuously distinguished himself j endeavors to represent the actual state of gynse- 
as a bold and successful operator, and who has | eological science and art.— British Medical Jour- 
devoted so much attention to the specialty, we i nal, May 16, 1885. 
feel sure the profession will not fail to appreciate | 



Tait's Diseases of Women and Abdominal Surgery. 

Diseases of Women and Abdominal Surgery. By Lawsox Tait, 
F. E. C. S., Professor of Gynaecology in Queen's College, Birmingham, late President of 
the British Gynecological Society, Fellow American Gynaecological Society. In two 
octavo vols. Vol. I., 554 pp., 62 engravings and 3 plates. Cloth, $3. Vol. IL, preparing. 
The plan of the work does not indicate the regu- I Much of the text is abundantly illustrated with 
lar system of a text book, and yet nearly every- cases, which add value in showing the results of 
thing of disease pertaining to the various organs | the suggested plans of treatment. We feel con- 
receives a fair consideration. The description of I fident that few gynecologists of the country will 
diseased conditions is exceedingly clear, and the I fail to place the work in their libraries. — The 
treatment, medical or surgical, is very satisfactory. | Obstetric Gazette, March, 1890. 



Edis on Diseases of Women. 

The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. Bv Arthur W. 
Edis, M. D., Lond., F. E. C. P., M. K. C. S., Assistant Obstetric Physician to Middlesex 
Hospital, late Physician to British Lying-in-Hospital. In one handsome octavo volume 
of 576 pages, with 148 illustrations. Cloth, $3.00; leather, $4.00. 
The special qualities which are conspicuous I among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages.— Boston 
Med. and Surg. Journ., March 2, 1882. 



are thoroughness in covering the whole ground, 
clearness of description and conciseness of state- 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Including Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, £1.50. 



WEST'S LECTURES ON THE DISEASES OF 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, $4.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



28 



Diseases of Women — (Continued). 



Thomas & Munde on Diseases of Women.— Sixth Edition. 

A Practical Treatise on the Diseases of Women. By T. Gaillakd 
Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of 
Physicians and Surgeons, New York, and Paul F. Munde, M.D., Professor of Gynecol- 
ogy in the New York Polyclinic. New (sixth) edition, thoroughly revised and rewritten 
by Dr. Munde. In one large and handsome octavo volume of 824 pages, with 347 
illustrations, of which 201 are new. Cloth, $5.00 ; leather, $6.00. 

Probably no treatise ever written by an Ameri- 
can author on a medical topic has been accepted 
by more practitioners, as a standard text-book, or 
read with pleasure and profit by more medical 
students than Thomas on the diseases of women. 



Next to the indescribable charm of listening to 
Dr. Thomas' lectures and clinics, which have in 
them the element of a captivating and inspiring 
personality— which must be heard and felt to be 
properly appreciated— is this volume, which in 
classic excellence, elegance of diction and scholar- 



ly and scientific statement must remain what it 
long has been, a standard text-book both for prac- 
titioner and student, at borne and abroad, and an 
enduring pride to American gynecologists. In a 
field by no means new or wanting in honorable 
achievement, Dr. Munde has added to his already 
enviable reputation by the manner in which he 
has acquitted himself in an undertaking at once 
so delicate and difficult and for which he will 
receive, at the hands of the profession, their ac- 
knowledgment. — The Brooklyn Med. Jour., Mar. '92. 



Sutton on the Ovaries and Fallopian Tubes. 

Surgical Diseases of the Ovaries and Fallopian Tubes, including 
Tubal Pregnancy. By J. Bland Sutton, F. E. C. S., Assistant Surgeon to the 
Middlesex Hospital, London. In one crown octavo volume of 544 pages, with 119 
engravings and 5 colored plates. Cloth, $3.00. 

To gynecologists the name of Mr. Sutton has 
long been familiar as that of a conscientious 
worker in pelvic pathology, as well as a compara- 
tive anatomist of wide reputation. The present 
vo ume contains the substance of valuable papers 
which have been scattered throughout journals 
and society reports during the past five or six 
years, and deserves the careful attention of gen- 
eral readers as well as of specialists. Everything 



that the writer has to say is stated in a clear, 
practical way. The author's style is singularly 
concise — almost epigrammatic. Statements which 
in a less weighty authority might appear too dog- 
matic gather force by the positive manner in 
which they are made. We have no hesitation in 
pronouncing it the best monograph of the kind 
which has yet appeared. — Medical Record, New 
York, May 21, 1892. 



Davenport's Non-Surgical Gynaecology.— Second Edition. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. 

Designed especially for the Use of Students and General Practitioners. By Francis 
H. Davenport, M. D., Assistant in Gynaecology in the Medical Department of Harvard 
University, Boston. New (second) edition. In one handsome 12mo. volume of 314 
pages, with 107 illustrations. Cloth, $1.75. 



The first edition of Dr. Davenport's book, which 
was published three years ago, evidently met with 
the reception it deserved, or the second edition 
would not have followed so soon. The title is an 
attractive one, and the contents are of value to the 
student and general practitioner. One advantage 
of it is that it teaches the physician or the student 
how to do the little things, or to remedy the 
minor evils in connection with gynaecology. In 
these days, when major gynaecology is so largely 



practised, minor gynecology is too frequently 
ignored. To those in the profession who are 
about to interest themselves particularly in this 
branch of surgery, and to the student who in the 
future intends to make gynaecology his life-work, 
we believe that Davenport's book will be essential 
to his success, because it will teach him facts 
which larger works sometimes ignore. — The Thera- 
peutic Gazette, October 15, 1892. 



May's Manual of Diseases of Women.— Second Edition. 

A Manual of theDiseases of Women. Being a concise and systematic 
exposition of the theory and practice of gynecology. By Charles H. May, M. D., 
late House Surgeon to Mount Sinai Hospital, New York. Second edition, edited by 
L. S. Kau, M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. 
volume of 360 pages, with 31 illustrations. Cloth, $1.75. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes aud ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily. — The Physician and 
Surgeon, June, 1890. 



Duncan on Diseases of Women. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint 
Bartholomew's Hospital. By J. Matthews Duncan, M. D. ; LL. D., F. K. S. E., etc. 
In one octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the text-books ; others 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that they deserve to be 
widely read.— N. Y. Medical Journal, March, 1880. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 



American from «fche third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Obstetrics. 



29 



Parvin's Science and Art of Obstetrics.— Second Edition. 

The Science and Art of Obstetrics. I Jy Thbophilus Pabvin,M.D., 
LL. D., Professor of Obstetrics and the Diseases of Womeo and Children in Jefferson 
Medical College, Philadelphia. Second edition. In one handsome 8vo. volume of 701 
pages, with 239 engravings and a colored plate. Cloth, $ L25; leather, $5.25. 

The second edition of this work is fully up to the | scholar and a master. Rarely in the range of 
present state of advancement of the obstetric art. obstetric literature can be found a work wl)i<h is 
The author has succeeded exceedingly well in j so comprehensive and yet compact and practical. 
Incorporating n.>w matter without apparently in- In such respect it is essentially a text book of the 
creasing the size of his work or interfering with first merit. The treatment of the subjects gives a 
the smoothness and grace of its literary construe- real value to the work — the individualities of a 
tion. He is very felicitous in his descriptions of I practical teacher, a skilful obstetrician, a close 
conditions, and proves himself in this respect a | thinker and a ripe scholar.— Med. Rec.,. Jan. 17, '91 



Playfair's Midwifery.— Eighth Edition. Just Ready. 

A Treatise on the Science and Practice of Midwifery. By W. S. 
Playfaik. M. D., F. E. C. P., Professor of Obstetric Medicine in King's College, Lon- 
don. Sixth American, from the eighth English edition. Edited, with additions, by 
Kobert P. Harris, M. D. In one handsome octavo volume of 697 pages, with 217 
engravings and 5 plates. Cloth, $4 00; leather, $5.00. 
A notice of the previous edit on is appended. 

Truly a wonderful book; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 
is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- j 



tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations, 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice, 
and also of all the coincident troubles connected 
therewith.— Southern Practitioner, Dec. 1889. 



King's Manual of Obstetrics.— Fifth Edition. 

A Manual of Obstetrics. By A. F. A. King, M. D., Professor of Obstetrics 
and Diseases of Women in the Medical Department of the Columbian University, Wash- 
ington, D. C, and in the University of Vermont, etc. Kew (fifth) edition. In one 12mo. 
volume of 446 pages, with 150 illustrations. Cloth, $2.50. 



So comprehensive a treatise could not be brought 
within the limits of a book of this size were not 
two things especially true. First, Dr. King is a 
teacher of many years' experience, and knows 
just how to present his subjects in a manner for 
them to be best received; and, secondly, he can 
put his ideas in a clear and concise form. In 
other words, he knows how to use the English 
language. He gives us the plain truth, free from 



unnecessary ornamentation. Therefore we say 
there are nine hundred pages of matter between 
the covers of this manual of four hundred and 
fifty pages. We cannot imagine a better manual 
for the hard- worked student ; while its clear and 
practical teachings make it invaluable to the busy 
practitioner. The illustrations add much to the 
subject, matter. — The National Medical Review, 
October, 1892. 



Barnes' System of Obstetric Medicine and Surgery. 

A System of Obstetric Medicine and Surgery, Theoretical and 
Clinical. For the Student and the Practitioner. By Eobert Barnes, M. D., Phys- 
ician to the General Lying-in Hospital, London, and Fancourt Barne?, M. D., Obstetric 
Physician to St. Thomas' Hospital, London. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 
It is not an exaggeration to say of the book that readily accessible and condensed form, ought to 
it is the best treatise in the English language yet own a copy of the book. — Journal of the American 
published. Every practitioner who desires to have Medical Association, June 12, 1886. 
the best obstetrical opinions of the time in a 



Landis on Labor and the Lying-in Period. 

The Management of Labor, and of the Lying-in Period. 
By Henry G. Landis, A. M., M. D., Professor of Obstetrics and the Diseases of Women 
in Starling Medical College, Columbus, Ohio. In one handsome 12mo. volume of 334 
pages, with 28 illustrations. Cloth, $1.75. 



LEISHMAN'S SYSTEM OF MIDWIFERY, IN- 
CLUDING THE DISEASES OF PREGNANCY 
AND THE PUERPERAL STATE. Fourth edi- 
tion. Octavo. 

PARRY ON EXTRA-UTERINE PREGNANCY: 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pages. Cloth, $2.50. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V. Keating, M. D , Professor of Obstetrics, 
etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 



octavo volume of 640 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, 87. 

CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, 82.50. 

TANNER ON PREGNANCY. Octavo, 490 pages, 
colored plates, 16 cuts. Cloth, $4.25 

WINCKEL'S COMPLETE TREATISE ON THE 
PATHOLOGY AND TREATMENT OF CHILD- 
BED. For Students and Practitioners. Trans- 
lated from the second German edition, by J. R. 
Chadwick, M. D. Octavo 484 pages. Cloth $4.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



30 



Dis. of Children, Obstetrics — (Cont'd), Manuals, 



Smith on Children.— Seventh Edition. 

A Treatise on the Diseases of Infancy and Childhood. By 

J. Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital 
Medical College, New York. New (seventh) edition, thoroughly revised and rewritten. 
Intone handsome octavo volume of 881 pages, with 51 illus. Cloth, $4.50 ; leather, $5.50. 

is always conservative and thorough, and the 
evidence of research has long since placed its 
author in the front rank of medical teachers. — 
The American Journal of the Medical Sciences, Dec. 
1891. 

In the present edition we notice that many of 
the chapters have been entirely rewritten. Full 
notice is taken of all the recent advances that 
have been made. Many diseases not previously 
treated of have received special chapters. The 
work is a very practical one. Especial care has 
been taken that the directions for treatment shall 
be particular and full. In no other work are such 
careful instructions given in the details of infant 
hygiene and the artificial feeding of infants. — 
Montreal Medical Journal, Feb. 1891. 



We have always considered Dr. Smith's book as 
one of the very best on the subject. It has always 
been practical— a field book, theoretical where 
theory has been deduced from practical experi- 
ence. He takes his theory from the bedside and 
the pathological laboratory. The very practical 
character of this book has always appealed to us. 
It is characteristic of Dr. Smith in all his writings 
to collect whatever recommendations are found in 
medical literature, and his search has been wide. 
One seldom fails to find here a practical suggestion 
after search in other works has been in vain. In 
the seventh edition we note a variety of changes 
in accordance with the progress of the times. It 
still stands foremost as the American text-book. 
The literary style could not be excelled, its advice 



Herman's First Lines in Midwifery. 

First Lines in Midwifery: a Guide to Attendance on Natural 
Labor for Medical Students and Midwives. By G. Ernest Herman, M. B., 

F.R.C. P., Obstetric Physician to the London Hospital. In one 12mo. yolume of 198 
pages, with 80 illustrations. Cloth, $1.25. See Students Series of Manuals, below. 

This is a little book, intended for the medical I will prove valuable to the beginner in midwifery 
student and the educated midwife. The work and could be read with advantage by the majority 
is written in a plain, simple style, and is as of practitioners, old and young. — The Medical 
much as possible devoid of technical terms. It | Fortnightly, April 15, 1892. 

Owen on Surgical Diseases of Children. 

Surgical Diseases of Children. By Edmund Owen, M. B., F. B. C. S., 

Surgeon to the Children's Hospital, Great Ormond Street, London. In one 12mo. vol- 
ume of 525 pages, with 4 chromo-lithographic plates and 85 woodcuts. Cloth, $2.00. 
See Series of Clinical Manuals, below. 



One is immediately struck on reading this book 
with its agreeable style and the evidence it every- 
where presents of the practical familiarity of its 
author with his subject. The book may be 



honestly recommended to both students and 
practitioners. It is full of sound information, 
pleasantly given.— Annals of Surgery, May, 1886. 



Student's Series of Manuals. 



A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Luff's Manual of Chem- 
istry, §2; Herman's Fbst Lines in Midwifery, $1.25; Treves' Manual of Surgery, by various writers, in 
three volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2; Gould's Surgical 
Diagnosis, $2; Robertson's Physiological Physics, $2; Bruce's Materia Medica and Therapeutics (5th edi- 
tion). $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's Dissectors'' Man- 
ual, $1.50 ; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical 
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75. The following is in press: 
Pepper's Forensic Medicine. For separate notices see index on last page. 

Series of Clinical Manuals. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative mortographs on important clinical subjects in a cheap and portable form. 
The volumes contain about 550 pages and are freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Yeo on Foodin Health and Disease, $2; Broadbent on 
the Pulse, $1.75; Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Marsh 
on the Joints, $2; Owen on Surgical Diseases of Children, $2; Morris on Surgical Diseases of the 
Kidney, $2.25; Pick on Fractures and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intesti- 
nal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. The following is in preparation: 
Lucas on Diseases of the Urethra. For separate notices see index on last page. 

Hartshorne's Conspectus of the Medical Sciences. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anat- 
omy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
By Henry Hartshorne, A. M., M. D., LL. D., lately Professor of Hygiene in the Uni- 
versity of Pennsylvania. Second edition, thoroughly revised and greatly improved. In 
one large royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5.00. 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
77a oaees. <"'ioth, $5.25 ; leather, §6.25. 

WEST ON SOME DISORDERS OF THE NERV- 
OUS SYSTEM IN CHILDHOOD. In one small 
12mo. volume of 127 pages. C.oth, $1.00. 

LUDLOW'S MANUAL OF EXAMINATIONS. A 
Manual of Examinations upon Anatomy, Physi- 



ology, Surgery, Practice of Medicine, Obstetrics, 
Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical 
Formulary. By J. L. Ludlow, M. D., Consulting 
Physician to the Philadelphia Hospital, etc. 
Third edition, thoroughly revised, and greatly 
enlarged. In one 12mo. volume of 81G pages, 
with 370 illustrations. Cloth, $3.25; leather, $3.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



fledical Jurisprudence, Historical. 



31 



Taylor's Medical Jurisprudence.— New Edition. Just Ready. 

A Manual of Medical Jurisprudence. By Axfbed S. Taylob, M. D., 

Lecturer on Med. Jurisprudence and Chemistry in City's EEosp., London. New American 
from the 12th English edition. Thoroughly revised by Clark BELL, Esq., of the New 
York Bar. In one octavo volume of 787 pages, with 56 illus. Cloth, $4.50; leather, $5.50. 

haps, can appreciate to their fullest extent.— The 
St. Louis Mtdieaf, and Surgical Journal, Dec, 1892. 
Taylor's Medical Jurisprudence is an old stand- 
ard. There is no other work upon the subject 
which has been so uniformly recognized or so 
widely quoted and followed by courts in England 
and this country. It would have been impossible 
to select anyone in this country better fitted for 
the task of revision than Mr. Bell. Profiting by 
the labors with which Dr. Stevenson has enriched 
the twelfth English edition, he has, in this 
eleventh American edition, given us a book fully 
abreast with the most recent thought and knowl- 
edge. On the basis of his own researches, of the 
investigations of scientists throughout the world, 
and of the decisions of our own courts, he has in- 



The work before us, which has become a classic, 
i9 the authority which has been adopted in all the 
English-speaking courts of justice, and this fact 
is due solely to the circumstance that it is a per- 
fectly reliable guide both in the matter of medical 
and legal authority. The last English edition has 
been much enriched by the additions of Dr. Stev- 
enson, a very acute and accurate editor. The 
American editor, Mr. Clark Bell, is peculiarly 
fitted for this task, and he further availed himself 
of the advice not only of eminent medi -al men, 
but of the suggestions' made by legal friends. All 
of these circumstances have combined in such a 
manner as to permit the publishers to present us 
with a work which, in our opinion, is without a 
peer in the English language. To the legal pro- 
fession it is of the greatest value, more especially | corporated in it a wealth of practical suggestion 
for the purposes of cross examination and the and instructive illustration which cannot fail to 
preparation of briefs One of the strong points of j strengthen the hold it has so long had upon the 
the book is the numerous citations which abound i profession.— The Criminal Law Magazine and Be- 
throughout, and which none but a lawyer, per- I porter, January, 1893. 



By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

Lea's Superstition and Force.— New Edition. Just Ready. 

Superstition and Force: Essays on The Wager of Law, The 
Wager of Battle, The Ordeal and Torture. By Henry Charles Lea, 
LL. L\, Xew (4th) edition, revised and enlarged. Koyal 12mo., 629 pages. Cloth, $2.75. 



Both abroad and at home the work has been 
accepted as a standard authority, and the author 
has endeavored by a complete revision and con- 
siderable additions to render it more worthy of 
the universal favor which has carried it to a 
fourth edition. The style is severe and simple, 
and yet delights with its elegance and reserved 
strength. Tne known erudition and fidelity of 
the author are guarantees that all possible origi- 
nal sources of information have been not only 
consulted but exhausted. The subject matter is 



handled in such an able and philosophic man- 
ner that to read and study it is a step toward 
liberal education. It is a comfort to read a book 
that is so thorough, well conceived and well done. 
We should like to see it made a text-book in our 
law schools and prescribed course for admission 
to the bar. — Legal Intelligencer, March 3, 1893. 

A work as remarkable for the wealth of histori- 
cal material treated as for the masterly style of 
the exposition.— London Saturday Review, Feb. 25, 
1893. 



By the same Author. 
Chapters from the Religious History of Spain, 
of 522 pages. Cloth $2.50. 

The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 
found are here applied to some side-issues of that 
great subject. We have only to say of this volume 



-In one 12mo. volume 



that it worthily complements the author's earlier 
studies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears on every page- 
London Antiquary, Jan. 1891. 



By the same Author. 
The Formulary of the Papal Penitentiary. 

pages, with a frontispiece. Cloth, S2.50. Just Ready. 



In one 8vo. volume of 221 



By the Same Author. 
Studies in Church History. The Hise of the Temporal Power— Ben- 
efit of Clergy— Excommunication— The Early Church and Slavery. Sec- 
ond and revised edition. In one royal octavo volume of 605 pages. Cloth, $2.50. 



The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it out to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 



makes the work particularly valuable to the student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 
complex or conflicting forces.— Boston Traveller. 



By the Same Author. 
An Historical Sketch of Sacerdotal Celibacy in the Christian 
Church. Second edition, enlarged. In one octavo volume of 685 pages. Cloth, $4.50. 
This subject has recently been treated with very l more light on the moral condition of the Middle 
great learning and with admirable impartiality by Ages, and none which is more fitted to dispel the 
an American author, Mr. Henry C. Lea, in his His- gross illusions concerning that period which posi- 
tory of S iCerdotal Celibacy, which is certainly one tlve writers and writers of a certain ecclesiastical 
of the most valuable works that America has pro- j school have conspired to sustain.— Lecky's History 
duced. Since the great history of Dean Milman, of European Morals, Chap. V. 
I know no work in English which has thrown I 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



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Abbott's Bacteriology . 

Allen's Anatomy . 

American Journal of the Medical Sciences 

American Systems of Gynecology and Obstetrics 

American System of Practical Medicine . 

American System of Dentistry 

Ashhurst's Surgery .... 

Ashwell on Diseases of Women 

Attfield's Chemistry .... 

Barlow's Practice of Medicine 

Barnes' System of Obstetric Medicine 

Bartholow on Cholera 

Bartholow on Electricity 

Basham on Penal Diseases . 

Bell's Comparative Anatomy and Physiology 7, : 

Bellamy's Surgical Anatomy 

Berry on the Eve .... 

Billings' National Medical Dictionary . 

Blandford on Insanity 

Bloxam's Chemistry .... 

Bristowe's Practice of Medicine 

Broadbent on the Pulse . . . .15. 

Browne on Koch's Remedy . 

Browne on the Throat, Nose and Ear 

Bruce's Materia Medica and Therapeutics . 11, 

Brunton's Materia Medica and Therapeutics 

Bryant's Practice of Surgery . 

Bumstead and Taylor on Venereal. See Taylor, 

Burnett on the Ear ..... 

Butlin on the Tongue . . . .20, 

Carpenter on the Use and Abuse of Alcohol 

Carpenter's Human Physiology 

Carter & Frost's Ophthalmic Surgery . .24, 

Chambers on Diet and Regimen . 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen's Applied Therapeutics 

Coleman's Dental Surgery . 

Condie on Diseases of Children 

Cornil on Syphilis .... 

Cullerier & Bumstead on Venereal 

Culver <fe Hay den on Venereal Diseases . 

Dalton on the Circulation 

Dalton's Human Physiology 

Davenport on Diseases of Women . 

Davis' Clinical Lectures 

Draper's Medical Phvsics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

Dungllson's Medical Dictionary 

Edes' Materia Medica and Therapeutics 

Edison Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology 

Erichsen's System of Surgery 

Farquharson's Therapeutics and Mat. Med. 

Field's Manual of Diseases of the Ear 

Flint on Auscultation and Percussion 

Flint on Phthisis 

Flint on Respiratory Organs 

Flint on the Heart 

Flint's Essays ..... 

Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

Fotnergill's Handbook of Treatment 

Fownes' Elementary Chemistry . 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages 

Gant's Student's Surgery 

Gibbes' Practical Pathology 

Gould's Surgical Diagnosis . . . .20, 

Gray on Nervous and Mental Diseases . 

Gray's Anatomy . ... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

Gross System of Surgery 

Habershon on the Abdomen 

Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hardaway on the Skin 

Hare's Practical Therapeutics 

Hare's System of Practical Therapeutics 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Herman's First Lines in Midwifery 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hirst & Piersol on Human Monstrosities 

Hoblyn's Medical Dictionary 

Hodge on Women 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

Holmes' Principles and Practice of Surgery 

Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever 

Hutchinson on Syphilis . . .25, 

Hyde on the Diseases of the Skin . 

Jackson on the Skin . 

Jamieson on the Skin 

Jones (0. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

King's Manual of Obstetrics . 



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Klein's Histology 

Landis on Labor 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Ej'elid 

Lea's Chapters from Religious History of Spain 

Lea's Formulary of ihe Papal Penitentiary 

Lea's Sacerdotal Celibacy 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis . . . . 

Lehmanh s Chemical Physiology . 

Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Luff's Manual of Chemistry 

Lyman's Practice of Medicine 

Lyons on Fe\ er ..... 

Maisch's Organic Materia Medica . 

Marsh on the Joints 

May on Diseases of Women . 

Medical News ..... 

Medical News Physicians' Ledger . 

Medical News Visiting List . 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Morris on Diseases of the Kidney . 

Musser's Medical Diagnosis . 

National Dispensatory 

National Medical Dictionary 

Nettleship on Diseases of the Eye . 

Norris and Oliver on the Eye 

Owen on Diseases of Children 

Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery . ... 

Pavy on Digestion and its Disorders 

Payne's General Pathology . 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pepper's System of Medicine 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery . 

Playfair on Nerve Prostration and Hysteria 

Playfair's Midwifery .... 

Politzer on the Ear .... 

Power's Human Phvsiology . 

Purdy on Bright's D'isease and Allied A Sections 

Pye-Smith on the Skin 

Quiz Series ..... 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Compend of Anatomy . 

Roberts' Surgery 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schofield's Physiology 

Schreiber on Massage .... 

Seiler on the Throat, Nose and Naso-Pharynx 

Senn's Surgical Bacteriology 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery 

Stille on Cholera 

StillS & Maisch's National Dispensatory 

Stilie's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 

Students' Quiz Series .... 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Sutton on the Ovaries and Fallopian Tubes 

Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Poisons .... 

Taylor on Venereal Diseases 

Taylor's Medical Jurisprudence 

Thomas & Munde on Diseases of Women 

Thompson on Stricture . . . 

Thompson on Urinary Organs 

Todd on Acute Diseases . ... 

Treves' Manual of Surgery . 

Treves on Intestinal Obstruction . 

Treves' Operative Surgery . 

Treves' Student's Handbook of Surg. Operations, 21 

Treves' Surgical Applied Anatomy . .6,30 

Tuke on the Influence of Mind on the Body . 17 

Vaughan & Novy's Ptomaines and Leucomaines 10 

Visiting List, The Medical News 

Walshe on the Heart . 

Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Wharton's Minor Surgery and Bandaging ' 

Whitla's Dictionary of Treatment 

Williams on Consumption .... 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry 

Year-Books of Treatment for 86, '87. '91, '92, '93. 

Yeo's Medical Treatment, or Clinical Therapeutics, 16 

Yeo on Food in Health and Disease . .16,30 

Young's Orthopaedic Surgery . 20 



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